LePino v. Anthem Blue Cross Life and Health Insurance Company

Background

Tricia LePino sued Anthem Blue Cross Life and Health Insurance Company for breach of contract, seeking benefits under a life-insurance policy covering her deceased spouse, John Capotorto, III. LePino was the policy’s sole beneficiary. She submitted a claim after Capotorto died on August 29, 2021. The death certificate listed the cause of death as acute intoxication from the combined effects of heroin, fentanyl, P-fluorofentanyl, and xylazine. Anthem denied the claim based on a policy exclusion for a death caused directly, wholly, or partly by being under the influence of a drug or substance.

The action was initially filed in New York state court and was later removed to the Southern District of New York. Anthem argued that the policy was governed by the Employee Retirement Income Security Act of 1974 (ERISA), which provides a federal framework for recovering benefits under certain employee benefit plans. Neither party challenged federal subject-matter jurisdiction or the characterization of the policy as an ERISA plan.

Motion and Arguments

Anthem moved to dismiss under Federal Rule of Civil Procedure 12(b)(6), which permits dismissal when a complaint does not state a legally sufficient claim. Anthem argued that no benefits were owed because the policy expressly excluded drug-related deaths.

LePino argued that the exclusion should apply only to deaths resulting from accidents—such as motor-vehicle or skiing accidents—that occurred while someone was under the influence of drugs or substances. She also argued that the exclusion did not clearly bar recovery because it did not specifically use the word “overdose.”

Court’s Analysis

The court held that the policy’s exclusion was unambiguous. It interpreted “being under the influence of” according to its ordinary meaning of being affected by a drug or substance. The court concluded that a death caused by acute intoxication from the listed substances fell within the exclusion. The policy’s definition of “drug or substance” also covered controlled substances, including heroin, fentanyl, and their derivatives.

The court rejected LePino’s narrower interpretation because the exclusion covered deaths caused “wholly or partly” by being under the influence of drugs. The court also concluded that the absence of the specific word “overdose” did not prevent the exclusion from applying. The court distinguished Miller v. Continental Insurance Co. because that case involved different exclusionary language concerning intentionally self-inflicted injuries, suicide, and accidents, rather than an exclusion specifically addressing drug-related deaths.

Disposition

The court granted Anthem’s Rule 12(b)(6) motion to dismiss and dismissed LePino’s claims without prejudice. The court granted LePino leave to amend her complaint by September 5, 2023. It directed Anthem to answer or seek permission to file another motion to dismiss by September 26, 2023. The order stated that failure to file a timely amended complaint would result in the action being deemed dismissed with prejudice. The clerk was directed to terminate the motion at ECF No. 13.