Denial Under Long Term Care Insurance

Claimant was heavy drinker but never any signs or treatment for addiction or alcoholism. Required long term care because of liver cirrhosis. Benefits are being denied based on an exclusion not to pay for confinements "that result from drug or alcohol addiction." Have you heard of similar issues?

Answer:
I would argue that the policy language is ambiguous. While the liver damage may have resulted from use of drugs or alcohol, the “confinement” did not result from the "addiction." I suspect a court would find that ambiguous since it could be interpreted either way. See, Western World Ins. Co. v. Markel American Ins. Co., 677 F.3d 1266 (10thCir. 2012): "Even viewed in its best light,the applicability of the escape clause to an entity, like Brewer, insured under Paragraph 1 is far from clear. And in these circumstances, Oklahoma contract law tells us the tie must go to the insured. "[I]f an insurer desires to limit its liability under a policy, it must employ language that clearly and distinctly reveals its stated purpose."Spears v. Shelter Mut. Ins. Co.,73 P.3d 865, 868 (Okla.2003). If (as here) the relevant limiting policy provisions are "unclear or obscure," then the objectively reasonable expectations of a person "in the position of the insured" control.Id.Put differently, when a policy's escape hatch is less a clearly marked exit than it is a hidden trap door, the reasonable expectations of an insured who has read and become familiar with the policy language supplies the rule of decision.SeeMax True Plastering Co. v. U.S. Fid. & Guar. Co.,912 P.2d 861, 864-65 (Okla.1996)."

You might also want to look at Andres v. Oklahoma Farm Bureau Mut. Ins. Co., 2009 OK CIV APP 97, 227 P.3d 1102, 1109: "where an ambiguity is found in the policy language, or where the exclusions are obscure or technical or are hidden in complex policy language, a court must resolve the ambiguity in a manner that conforms the policy to the parties "reasonable expectations."Max True Plastering Co. v. U.S. Fid. and Guar. Co.,1996 OK 28, 912 P.2d 861.In other words, a policy or provision thereof will be construed, not by what the drafter necessarily intended, but by what a reasonable person in the position of the insured would have understood the term or policy to mean.American Econ. Ins. Co. v. Bogdahn,2004 OK 9, ¶ 9, 89 P.3d 1051, 1054.This is called the doctrine of reasonable expectations."