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Avoid an insurance disaster: Don't drink and land in the ER

By Michele Lerner on June 25th, 2012

Some health insurance companies have policies that exclude coverage of any health care treatments for patients who are under the influence of alcohol.

Individual claims depend on a variety of factors, but some insurance companies have written policies that allow them to deny coverage of claims for patients with alcohol in their bloodstream. State regulations can impact whether or not a claim can be denied because of alcohol use.

In January 2011, 26 states had regulations that specifically permit health insurance companies to deny coverage of claims of policyholders who had been drinking. In 17 states, denial of coverage because of alcohol is specifically prohibited.

State regulations related to insurance and alcohol began being implemented after 1947 when the National Association of Insurance Commissioners (NAIC) recommended that insurance coverage be denied for people who had been drinking. In 2001, this recommendation was reversed, in part because of the recognition that alcoholism is a treatable disease.

Alcohol and emergency rooms

Not every patient who visits a hospital emergency room or a trauma center is drunk or suffering from alcohol poisoning. But many patients have been drinking. If you've had one drink and then fall on the dance floor and twist your ankle, you may need an X-ray or some stitches. But if your insurance company has an alcohol exclusion, you could end up with a hefty medical bill.

Since many emergency room staff members are aware of the potential for a health insurance denial, some opt to avoid urine or blood tests that could show the presence of alcohol.

Health insurance policies and alcohol

To protect yourself from a health insurance denial, check your insurance policy for an alcohol-related exclusion. Also, check your state regulations to see if these denials are permitted or prohibited.

If a health insurance claim is denied, you must be given a reason for the denial and your insurance company must provide you with information about how to appeal a denial.

Michele Lerner

Michele Lerner, author of "HOMEBUYING: Tough Times, First Time, Any Time", has been writing about personal finance and real estate for more than two decades for a variety of publications and websites including Investopedia, Insurance.com, HSH.com, SavingsAccount.com, National Real Estate Investor magazine, The Washington Times, Urban Land magazine, NAREIT's REIT magazine and numerous Realtor associations.


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