Prelutsky, a partner in a law firm, was a participant in an ERISA plan and was insured under a group disability policy. While on a ski vacation in Aspen, he fell down a flight of stairs, resulting in traumatic brain injuries. No one witnessed the fall. His son found him unconscious.
Within 20 minutes after arriving at the hospital, Prelutsky’s blood alcohol concentration ("BAC") was 281 mg/dL. The test records stated: “These unconfirmed ‘screening’ results are to be used for medical purposes only. They are not intended for non-medical purposes (e.g., employment and/or legal testing).” The medical records were replete with other references to Prelutsky’s intoxication, including: “Patient ... drank heavily this evening; fall 20 carpeted steps with immediate loss of consciousness. His son and family friends are present in the ER.”
Three weeks later, Prelutsky was transferred to a long-term rehabilitation facility. The admitting physician noted that Prelutsky had a history of binge drinking and that he was intoxicated when he fell. The records from the rehabilitation facility contained several references to Prelutsky’s “blood alcohol level of 0.25 at the time of his fall.”
Prelutsky submitted a claim for benefits. The insurer had discretionary authority to administer the claim and was responsible for paying benefits. Under the group policy, disability caused by, resulting from, or related to intoxication was excluded from coverage.
The insurer denied Prelutsky’s claim based on the intoxication exclusion, citing a federal regulation describing physical and mental symptoms associated with a BAC between 0.20 and 0.29 (e.g., stupor, severe motor impairment, loss of understanding, impaired sensation, loss of consciousness, possibility of falling).
Prelutsky appealed, submitting an affidavit from the owner of the Aspen home, who stated she did not see Prelutsky fall, but he did not appear intoxicated before the fall. The owner speculated that Prelutsky tripped over his ski pants.
The insurer obtained an independent medical records review. Citing medical treatises, the physician noted that at “0.25% BAC, the individual needs assistance in walking, and experiences total mental confusion.” Because Prelutsky’s BAC was .281 at the time, the physician opined that intoxication most probably contributed to the fall. The insurer upheld its claim decision.
Prelutsky filed suit. On cross-motions for judgment, the court noted that the insurer had a minimal burden of proof (i.e., to show that the injury was “related to” intoxication) and that the deferential standard of review applicable in ERISA cases applied. But the court granted judgment for Prelutsky, finding the insurer’s decision to be both de novo wrong and an abuse of discretion.
The court found the evidence sufficient to establish that Prelutsky was intoxicated at the time of the fall, stating it was reasonable to place more weight on the medical evidence than the homeowner’s personal opinion that Prelutsky did not appear intoxicated.
The court construed the intoxication exclusion to require a causal link between Prelutsky’s intoxication and his loss. Citing Capone v. Aetna Life Ins. Co., 592 F.3d 1189 (11th Cir. 2010), and cases from other jurisdictions, the court concluded the insurer could not sustain its burden by relying solely on Prelutsky's BAC and a general list of alcohol’s effects. Nor would a medical expert’s opinion as to causation be sufficient if based solely on such evidence.
Thus, the court concluded the insurer was required to conduct a further investigation to determine if Prelutsky's intoxication resulted in a “degradation of his physical and cognitive abilities such that the causal link can reasonably be drawn between the injury and intoxication.” The court rejected the insurer’s argument that, because there was no eyewitness, further investigation would not have yielded any information as to the cause of the fall.
The court suggested that Prelutsky's son and the family friends who were in the ER could have provided additional information "regarding Plaintiff's physical and mental state immediately preceding the fall." The court identified additional "facts that logically could [have been] investigated to evaluate the relationship between the intoxication and the fall," such as the volume of alcohol consumed, the type of alcohol consumed, the time period over which it was consumed, whether Prelutsky was tired as a result of physical activity, and whether he was wearing attire that might cause a fall.
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