Barriers in the United States to implementing alcohol screening in hospital emergency departments:
There are a number of reasons for the relative lack of screening for alcohol problems. These include the incorrect belief that treatment is ineffective, as well as the perennial complaints of lack of time and resources. However, an additional reason sometimes voiced is that screening may have an adverse effect on patients. Many physicians rightly believe that insurance companies can deny coverage for an injury if alcohol is involved, similar to the denial of coverage for self-inflicted trauma. There is also concern that information about alcohol use at the time of the injury can be used against the patient in civil and criminal legal actions. The unfortunate result is that patients with a serious chronic illness are not receiving proper comprehensive care, that is, screening, identification, and treatment.
We therefore sought to determine the legal ability of insurance carriers to deny coverage for the trauma care of a patient who was intoxicated at the time of injury. We first sought to obtain data from the insurance commissioners in all 50 states. Of the 31 states that complied with data, 26 stated that an exclusion of coverage would be allowed if the insured person was intoxicated at the time of injury. The majority of the respondents claimed that if the insurance contract, agreed to by the patient, contained a specific exclusion for injuries due to intoxication, the insurer can legally deny coverage for the care.
Prompted by the similar wording of the exclusions referenced in the survey of insurance commissioners, we examined the relevant statutes governing insurance in all 50 states, as well as contacted the National Association of Insurance Commissioners. This revealed that the exclusion of coverage for injuries involving alcohol was based on a model law, the Uniform Accident and Sickness Policy Provision Law, promulgated by the National Association some four decades ago. An optional provision allowing the denial of coverage for alcohol related injuries states that: "Intoxicants and Narcotics: The insurer shall not be liable for any loss sustained or contracted in consequence of the insuredís being intoxicated or under the influence of any narcotic unless administered on the advice of a physician." Similar provisions allow for the exclusion of coverage for acute medical care of suicide attempts.
Thirty-eight states and the District of Columbia have adopted this provision in their insurance codes, allowing companies to write policies which deny coverage for injuries due to intoxication (Table 8). Two states, Minnesota and Oklahoma, allow insurers to deny coverage only if the insured is under the influence of narcotics, not alcohol, at the time of injury. New York and South Dakota only allow the insurer to deny the claim if the injury is sustained while the insured is in the act of committing a felony. Statutes concerning insurance policies in the remaining eight states are silent on the issue of denial of coverage.
8: State statues governing exclusion of coverage
When responding to our requests, many state insurance commissioners expressed the sentiment that policies will not cover injuries sustained while intoxicated because these injuries are viewed as self-inflicted or self-induced. That is, by drinking alcohol, people knowingly put themselves in harmís way. In their view, denying a claim based on the provision that the carrier is not liable for coverage of injuries sustained under the influence of alcohol is similar to denying coverage for self-inflicted injuries in a suicide attempt.
In most states, then, the insurance companies do have the legal right to deny coverage for an injury due to alcohol use. While this option appears to be enforced rarely by most companies, at least one insurer reported to us that they "strongly enforced" the exclusion policy if alcohol was involved. Unfortunately, physiciansí concerns about the implications of screening for alcohol use and abuse appear to be based on firm reality as codified in the statutes in most states. Such policies clearly have a dampening effect on the recommendations of physicians to screen all trauma patients for alcohol problems. Given that intervention for alcohol abuse and dependency is effective at reducing alcohol related injury recurrence, failure to screen and intervene is a clear disservice to these patients. We realize that insurance rates are set based on expenses incurred by companies and that coverage of care for injuries involving alcohol will potentially affect the premiums of others. However, alcohol abuse and dependency is a disease and insurance premiums should be based on risk sharing for all diseases.
Alternative strategies for caring for trauma patients with alcohol abuse or dependency include:
Change insurance statutes: At least 12 states have specifically chosen not to adopt the model law giving insurers statutory authority to write policies excluding coverage for injuries due to alcohol use. While most insurance companies will not enforce this provision frequently, some will. Coverage for care is ever changing and extremely confusing for patients and physicians alike. The existence of even one company which routinely excludes coverage affects how physicians treat all patients. A change in the regulatory statutes would be the clearest method to guarantee that coverage is not denied. This has been done nationally to end the practice of excluding coverage for "pre-existing" conditions.