Court upholds MiCare denial of coverage for man who was drunk when he was injured

By Bill Jaynes

The Kaselehlie Press

June 12, 2018

Pohnpei—After four years, the FSM Supreme Court has sided with MiCare for denying coverage to a man who injured himself while intoxicated.

FSM Supreme Court Associate Justice Beauleen Carl-Worswick decided the case on June 7, 2018 and her Finding of Fact and Conclusions of Law were entered on June 12.  The original complaint was filed in the court on February 5, 2014.  The causes of action were an appeal of a decision of an administrative agency, violations of regulations, breach of contract, due process, equal protection, civil rights violations, declaratory and injunctive relief, and breach of implied covenant of good faith and fair dealings.

The finding of facts says that on the evening of his injury on March 22, 2013, the plaintiff and another man consumed two five dollar bottles of sakau, a bottle of 80 proof vodka, one beer, and an unidentified mixed drink.  At trial in February of this year, the plaintiff admitted that he was intoxicated.

While on his way home after consuming the alcohol and sakau, the man stopped in Metipw, U to relieve himself.  While standing on a ridge on the side of a river, he fell, sustaining serious injuries that meant that he can no longer climb or run, and he now walks with a permanent limp.

The physician who attended him at Pohnpei State Hospital Emergency Room said that the man sustained a severe cut on his forehead, looked drowsy and appeared to be intoxicated.  Pohnpei State Hospital recommended that he receive further treatment in the Philippines.

MiCare denied coverage for the referral.  The man appealed the decision and after an administrative review in August of 2013, the MiCare board upheld the rejection.  In February of 2014, the plaintiff filed his petition with the FSM Supreme Court.

The Court’s Conclusions of Law quoted Section 7.3 of the MiCare Regulations that lists excluded medical conditions that are not eligible for medical insurance coverage.  Section 7.3 (r) excludes, “treatment of injuries which are attributable to the member’s own misconduct, negligence, intemperate use of drugs or alcohol, direct participation in the commission of a crime, violation of law or ordinance, and unnecessary exposure to health hazards.”

At trial, the plaintiff admitted that he was “sakaula”.  That combined with the fact that although no blood or alcohol test was performed on the night of the plaintiff’s injury, the attending physician who treated him testified that he was drunk.

The court also considered whether the plaintiff would have fallen from the ridge had he not been intoxicated.  But though the plaintiff argued during closing statements that he might have fallen whether he was intoxicated or not, the matter was never raised in the plaintiff’s “case in chief”.  “Had the plaintiff proven that a reasonable or ordinary non-intoxicated person would have fell at the same location, then alcohol would not be a contributing factor to the fall, and MiCare would be obligated to provide coverage,” the ruling said.

The court dismissed all of the plaintiff’s claims.

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