FEDERAL COURT IN AUSTIN GRANTS SUMMARY JUDGMENT IN FAVOR OF INSURER IN NARCOTICS EXCLUSION DISPUTE
Last week, federal District Judge Sam Sparks ruled in favor of Humana Insurance Company in a lawsuit brought after Humana’s denial of healthcare benefits in Crose v. Humana Ins. Co., No. A-14-CA-205-SS, 2015 WL 3467160 (W.D. Tex. May 28, 2015). The claim arose when Ron Crose, a policyholder of Humana, suffered a stroke after ingesting MDMA, commonly known as “ecstacy.” Humana denied his claim for health benefits after determining that his injuries were excluded by the policy because they were “due to being intoxicated or under the influence of any narcotic unless administered on the advice of a health care practitioner.”
In analyzing whether the exclusion applied, the Court first addressed the plaintiff’s argument that MDMA was not a “narcotic” within the meaning of the policy. The plaintiff argued that narcotics referred only opium, opiates, cocaine, and related substances, that that the term “narcotics” was therefore ambiguous that required construction in favor of the insured. The Court acknowledged that this was a legitimate argument, looking to the Texas Controlled Substances Act and its federal counterpart that classified MDMA as a “hallucinogen,” with a separate definition of “narcotic” that did not include MDMA. However, the Court rejected these technical definitions and instead followed general rules of contract interpretation that look to a term’s “ordinary and generally-accepted meaning.” The Court concluded that the common meaning of “narcotic” is “illegal drug” and held that MDMA was therefore a “narcotic” within the meaning of the policy exclusion.
The Court next considered whether Mr. Crose’s stroke was “due to…being under the influence of [MDMA].” The plaintiff argued that this causation analysis required Humana to “prove, to a reasonable degree of medical certainty, based on a reasonable medical probability and scientifically reliable evidence,” that the MDMA caused the stroke. Humana countered that it needed only to demonstrate that the MDMA was a cause, not the sole cause, of the stroke. The Court considered a variety of cases discussing similar causation issues, including a Fifth Circuit case observing that “Texas cases generally interpret alcohol exclusions to apply even where alcohol is not the sole cause of death.” Likens v. Hartford Life & Accident Ins. Co., 668 F.3d 197, 202 (5th Cir. 2012). Finding that these cases did not provide a definitive answer and that the phrase “due to” was ambiguous, the Court settled on requiring proximate causation, which requires “a substantial factor in bringing about injury or death, and without which the injury or death would not have occurred.”
The Court then looked to the summary-judgment evidence and found that Humana had met its burden of proving that Mr. Crose’s MDMA ingestion proximately caused his stroke. First, his treating physician believed that the MDMA ingestion led to uncontrolled hypertension, which in turn caused the stroke. Second, the connections between MDMA, hypertension, and stroke were well documented in the evidence submitted by both parties. Third, Mr. Crose’s treating physicians provided no alternative explanations for the stroke. Finding no genuine issue of material fact regarding whether the stroke was “due to” narcotics ingestion, the Court granted summary judgment in favor of Humana and dismissed plaintiff’s Insurance Code claims.