Issued and entered this 8 th day of September 2009 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND

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1 STATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION Before the Commissioner of Financial and Insurance Regulation In the matter of XXXXX Petitioner File No v Assurity Life Insurance Company Respondent / Issued and entered this 8 th day of September 2009 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND On March 6, 2009, XXXXX ( Petitioner ) filed a request for external review with the Commissioner of Financial and Insurance Regulation under the Patient s Right to Independent Review Act, MCL et seq. After a preliminary review of the material submitted the Commissioner accepted the request on March 11, The Petitioner is covered under a fully insured individual policy underwritten by Assurity Life Insurance Company (Assurity Life). The issue in this matter can be decided by analyzing the Petitioner s insurance policy, the contract that defines the Petitioner s health care coverage. The Commissioner reviews contractual issues under MCL (7). No medical issues are presented requiring analysis by an independent medical review organization. II FACTUAL BACKGROUND On April 15, 2008, the Petitioner went to the emergency room of St. Anthony Memorial

2 Page 2 Hospital in Michigan City, Indiana. Petitioner was evaluated and released the same day. He received follow-up care, in the form of physician office visits, through the end of the month at Southwestern Medical Clinic. Respondent declined to provide coverage for the emergency room visit and the follow-up care, ruling that the treatment was excluded from coverage under the policy. Petitioner appealed the claims denial. Respondent did not alter its initial decision and issued a final adverse determination on February 24, III ISSUE Was Respondent correct in denying coverage for Petitioner s care? Respondent s Argument IV ANALYSIS In its final adverse determination, Assurity Life stated that Petitioner s policy excludes coverage for self-inflicted sickness. Assurity Life explains its decision to deny coverage in this way: Petitioner s Argument The self-inflicted Sickness Policy exclusion, as applied to the facts provided, show that; 1) The drinking was intentional, 2) The intentional drinking of alcohol caused the Sickness, and 3) The Sickness resulted in the loss. The necessary and only conclusion is that your Sickness was self-inflicted and, thus, was excluded. This is a Policy provision issue. It is specifically a listed Exclusion in the Policy. No further benefits are due. In his request for external review, the Petitioner states that his insurer is wrong to deny his claims on the grounds that he has caused a self-inflicted injury or sickness through alcohol abuse. He says that he is not an alcoholic and has no history of alcohol abuse. Petitioner says that on one particular night (he did not specify the date) he was in a place where he drank and where additional alcohol was added to his beverage without his knowledge. He says that as a result he got alcohol poisoning and saw his doctor for abdominal pains. (The dates of these events are not specified by Petitioner.)

3 Page 3 Commissioner s Review As noted above, Petitioner went to the emergency room of St. Anthony Memorial Hospital on April 15, He arrived at 7:48 am and was there for two hours. According to the notes of the treating physician, the Petitioner s chief complaint was alcoholism. The physician s notes state: The patient was brought to the facility by car because of alcohol addiction. There has been no known seizure activity. Patient s last alcoholic drink was 4 days ago. There has been no fever. There is no history of incontinence. There has been no history of gastro-intestinal bleeding. Patient has been addicted to vodka for the last several years. Patient has not been in alcohol rehab program. Patient denied any suicidal or homicidal ideations. Patient denies any medical complaints. Patient denies any chest or belly pain. Denies any falls or head injuries. Denies any neck discomfort. There has been mild dizziness, no confusion. He says that his face is flushed. Patient is not intoxicated at this point. He is fully alert and communicative. He has a very anxious predisposition, agonizing over cirrhosis of the liver and asking me repeatedly the same questions. Prior to discharge, Petitioner was provided with a list of local rehabilitation centers. He was advised to call one of them and arrange for further evaluation and management. He was also advised to abstain from alcohol use and to arrange a follow-up evaluation with his primary care physician within the next two days. The following day, Petitioner was seen at the Southwestern Medical Clinic by Dr. XXXXX who was Petitioner s primary care physician. Dr. XXXXX s notes indicate that Petitioner came for a general medical follow up but also reported an additional complaint of alcoholism. Dr. XXXXX prescribed Ativan and ordered additional tests. In subsequent visits that month, Dr. XXXXX noted that Petitioner had made arrangements to meet with an alcohol counselor. The Petitioner s policy includes coverage for both hospital emergency room care and physician office visits as well as substance abuse services. In its final adverse determination, Assurity Life did not question whether Petitioner s emergency room visit was a genuine medical emergency. Instead, Assurity Life chose to deny coverage for the reason that Petitioner was seeking treatment for a self-inflicted illness which is a class of illness excluded from coverage. Petitioner s policy includes these provisions which Assurity Life cited in denying coverage:

4 Page 4 Exclusions, Exceptions and Limitations (Applicable to All Coverages) NO payment will be made under the Policy for Expenses Incurred by any Insured Person for the following situations: 12) for treatment of services related to mental, nervous, emotional disorders; alcoholism; alcohol abuse; controlled Substance Abuse; Substance Abuse; Drug Abuse; and chemical dependency, including but not limited to the following treatments: counseling, detoxification, diagnostic evaluation, Hospital Confinement, ancillary or related services ) for professional services, regardless of the type in connection with mental illness or functional nervous disorders, or emotional disorders of any type or cause, alcoholism, controlled Substance Abuse or chemical dependency... The treating physician s records, created at the time of the emergency room visit, describe Petitioner s visit as attributable to Petitioner s concerns about alcoholism and its possible medical consequences. Petitioner s subsequent visits to Dr. XXXXX appear to have been prompted by the emergency room physician s advice. Michigan law requires insurers to provide some substance abuse treatment in their policies. Section 3425 of the Michigan Insurance Code provides: (1) Each insurer offering health insurance policies in this state shall provide coverage for intermediate and outpatient care for substance abuse, upon issuance or renewal, in all contracts for, group and individual hospital, medical, surgical expense-incurred health insurance policies other than limited classification policies. (3) Charges, terms, and conditions for the coverage required to be provided under subsection (1) shall not be less favorable than the maximum prescribed for any other comparable service. (4) The coverage required to be provided under subsection (1) shall not be reduced by terms or conditions which apply to other items of coverage in a health insurance policy, group or individual. This subsection shall not be construed to prohibit health insurance policies that provide for deductibles and copayment provisions for coverage for intermediate and outpatient care for substance abuse. (5) The coverage required to be provided under subsection (1) shall, at a minimum, provide for up to $1, in benefits for intermediate and outpatient care for substance abuse per individual per year. This minimum shall be adjusted annually by March 31 each year in accordance with the annual average

5 Page 5 percentage increase or decrease in the United States consumer price index for the 12-month period ending the preceding December 31. (7) This section shall take effect January 1, Section 3609a of the Michigan Insurance Code provides: (1) An insurer which delivers, issues for delivery, or renews in this state a policy of group disability insurance shall offer to include in that policy a provision that the insurer will provide coverage for inpatient care for substance abuse to the extent agreed upon between the insured employer or other insured organization and the insurer, to be provided in a facility approved by the department of public health for hospitalization or treatment of substance abuse. This coverage shall be subject to the provisions of sections 3406 to 3466, except sections 3425, 3438, and (2) An insurer which delivers, issues for delivery, or renews in this state a policy of group disability insurance shall include in that policy a provision that the insurer will provide coverage for intermediate and outpatient care for substance abuse, to the extent required by section (3) This section shall take effect January 1, Given these two statutory mandates, Respondent may not completely exclude substance abuse treatment, as it did in this case when it denied Petitioner s claims. Respondent made no argument that the emergency room and office visits were not medically necessary. Because Respondent s reason for denying the claims was not permissible under Michigan law, the denials are not upheld. ORDER The Commissioner reverses Assurity Life Insurance Company s adverse determination. Asurity Life shall provide coverage for the emergency room care and office visits, subject to any applicable co-payments and deductibles. Assurity Life shall provide the Commissioner proof of coverage no later than seven days from the date of payment. To enforce this Order, the Petitioner must report any complaint of noncompliance to the Office of Financial and Insurance Regulation, Health Plans Division, toll free at This is a final decision of an administrative agency. Under MCL , any person

6 Page 6 aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the circuit court for the county where the covered person resides or in the circuit court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of Financial and Insurance Regulation, Health Plans Division, P. O. Box 30220, Lansing, MI