State RegulationsNY specificDifficulty 2/5
After a wedding in Buffalo, an insured is seriously injured while intoxicated and files a claim under his individual accident and health policy, which contains the statutory intoxicants provision. The insurer denies the claim. Is the denial proper?
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
Under N.Y. Ins. Law §3216(d)(2)(K), the policy may provide that the insurer is not liable for a loss sustained as a result of the insured's being under the influence of intoxicants. Because the injury occurred while the insured was intoxicated, the denial is proper under the policy's statutory intoxicants provision. The exclusion does not require proof that the insured intended to become intoxicated, and it operates in individual policies just as it does in group coverage.
Why the other options are wrong
- A) The provision reaches intoxicants and narcotics alike; it is not a drug-only exclusion.
- B) Intent plays no role; the exclusion turns on the insured's condition at the time of the loss, not on whether the intoxication was deliberate.
- D) N.Y. Ins. Law §3216 governs individual policies, so the intoxicants exclusion operates in individual accident and health coverage as well.
Memory hook
Drunk in Buffalo, denied in Buffalo - intoxication at the time of loss triggers the statutory exclusion.