Mark Moffitt said:
We live in Nebraska, but group heath plan is from Insurance company in Pennsylvania. In emotional distress, my 16 year old daughter (normally very well adjusted) took 25 aspirin. The bill for emergency room and one night in ICU came to $5200. Health plan refusing to pay based on one line clause: "will not pay benefits for self inflicted injury." They will pay for alcohol and drug abuse symptoms and recovery, as well as mental health/counseling. This claim seems like a combination of both all in one night. Can I fight this and win?
My response:
In her statement to the insurance company, what was said about this incident in terms of her wanting to do bodily harm to herself ?
In the doctor's report to the insurance company, what was said about this incident in terms of her wanting to do bodily harm to herself ?
In the main, drug and alcohol abuse are long term problems, and not taken for purposes of "inflicting self injury" with the "intent" to do bodily harm - - although, as you and I know, is the end manifestation of such abuse.
However, I believe, your daughter's coverage in "this" instance depends largely upon her "intent" at the time she took the aspirins.
IAAL
