The Impact of the Opioid Crisis on Claims

With America’s epidemic of drug abuse, including opioids, illegal synthetic and designer drugs, and toxic substances from other countries purchased online, not to mention abuse of alcohol and marijuana, where do we begin to help AD&D claim analysts make decisions as they review these very complex claims?

Begin with the certified final death certificate documentation of cause of death (COD) and manner of death (MOD). Too simple? Perhaps not; it may be useful to explain why knowledgeable medical examiners and coroners document these acute intoxication cases as “accident.”

The U.S. utilizes what’s called the U.S. Standard Certificate of Death; states have their own variations of this, but they all essentially contain the same or similar sections, based on the U.S. Standard. As such, COD and MOD are sections in all state death certificates that must be completed by the certifier (medical examiner, attending physician, or coroner). In most states there are only five acceptable options for MOD classification: natural, accident, suicide, homicide, and undetermined.

The guideline from the National Association of Medical Examiners explains that the MOD classification is an American invention, and MOD is not addressed directly in the International Classification of Diseases as promulgated by the World Health Organization (WHO). MOD was added to the death certificate in the U.S. in 1910 by public health officials for the purpose of compiling death statistics, not as a legally binding opinion. This document further explains that “deaths directly due to toxic effects of a drug or poison (i.e., poisoning) … have traditionally been classified as Accident” (assuming there was no intent for self-harm or cause death since that MOD would then be considered suicide.)[1] 

The medical examiner is not the individual, in accordance with insurance policy language, that is the ultimate answer for cause of death due to the legal restrictions under which MEs are expected to base their opinions.

Suicide is the 10^th leading cause of death in the U.S. and has surpassed motor vehicle crashes as the leading cause of injury mortality. Although these rankings alone attest that suicide is a major public health problem, suicide and other self-directed violence fatalities are likely grossly underestimated. Suicide itself is undercounted. The rapidly growing burden of deaths from drug intoxication, whether related to prescribed or illicit compounds, likely obscures drug intoxication suicides.

Moreover, the vast majority of drug-related poisoning deaths reflect self-intoxicating behavior, but these deaths are seldom characterized as such. Rather, they are usually called “accidents” and typically assume public prominence only when they involve the premature deaths of celebrities such as Philip Seymour Hoffman, John Belushi, Elvis Presley, and Janis Joplin. Although their deaths may have been unintentional, there was nothing unintentional about their use of intoxicating substances. Therefore, the resulting fatal drug overdoses or interactions were not entirely accidental, or at least not entirely unforeseen.[2]   

As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by classifying most of these deaths as a result of self-intoxication. ResearchGate, an online professional network for scientists and researchers, has proposed that deaths from drug self-intoxication and investigations of all poisoning deaths should be incorporated into the National Violent Death Reporting System, which contains misclassified homicides and deaths of undetermined intent, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities.[3] 

Because it may take a while for the National Violent Death Reporting System to be accepted and instituted, would it not be best for individual payors of AD&D claims to incorporate exclusion language that covers drug abuse/self-intoxication as a non-accidental death? Insurers I have spoken to about developing such language believe that although it will not be easy, it will happen in time.

Until each payor has the appropriate exclusion language in place for the benefit of claim analysts, it is imperative that analysts be encouraged to realize the importance of continuing to use and hone their forensic investigating skills. It is critical that they assess the totality of the facts and circumstances surrounding the claim and be able to provide the beneficiary with a reasoned claim decision that is supported by substantial evidence contained in the administrative record.