A Kitchener, Ont. man who ended up in hospital while visiting family in the United States has learned the hard way that drinking alcohol can nullify your claim to insurance coverage.
Ernie Ceres flew down to New York on Sept. 18 for a family funeral and spent the first evening visiting with his brother, whom he hadn't seen in several years.
According to his girlfriend Lucy Reis, who stayed behind in Cambridge, Ont., Ceres was drinking with his brother before he left to spend the night at his son's house.
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"Ernie told his son to go ahead, because he's a little bit slow," Reis said. "The next thing he knew is his dad had fallen down at least ten to 12 stairs."
Ceres was unconscious and was rushed to Kings County Hospital, where doctors discovered bleeding in his brain.
His son called Reis with the news and she immediately booked a flight down to New York. Then she called the Canadian Automobile Association – Ceres's insurance provider – to file a claim.
Ceres was a frequent traveller and Reis said that for the past four or five years he had been buying CAA's multi-trip annual plan travel insurance.
Alcohol exclusion clause
A few days after calling them, she says she was told that the claim had been denied, because Ceres had too much alcohol in his blood at the time of the fall.
According to CAA's travel insurance policy, the provider does not have to pay medical expenses in the case of "alcohol related sickness, death or injury or the abuse of medication, drugs, alcohol or any other toxic substance."
Also, according to the policy, "alcohol abuse includes having a blood alcohol level in excess of 80 milligrams of alcohol per 100 millilitres of blood."
Exclusion not stated up front
It is unclear what Ceres's blood alcohol level was when he was admitted to hospital; however, if it was over 0.08 per cent, it would give CAA cause to deny his claim.
'You've got to know what you're buying.' - Marvin Ryder, professor of marketing and entrepreneurship
But Reis said that CAA did not tell Ceres that drinking could nullify his claim to insurance coverage, and for that reason the company should pay for the health care he is receiving in the United States.
"He's purchased a product and not been informed," she said. "I understand that some of it was his responsibility to read the fine print, but let's be serious, people buy insurance all the time and you just expect the person you're buying it from is selling you a product that they're going to stand by."
Consumer responsible to know
When asked whether CAA was obligated to tell Ceres that drinking could affect his insurance eligibility, industry experts all agreed that the company was not liable.
According to the Travel Health Insurance Association of Canada, it is the traveller's responsibility to know what their policy does and does not cover.
"You need to understand your policy and you need to take time to read that policy document," said association president Will McAleer. "In this case, I certainly would have thought there would have been the opportunity and responsibility to take a look and see whether or not there is an exclusion related to excess alcohol consumption."
You must read fine print
The policy document for CAA's travel health insurance is more than 50 pages long and is available online. The exclusion related to alcohol is on page 14.
"Is it realistic to read all of this? Maybe it's not," said Marvin Ryder, a professor of marketing and entrepreneurship with the Degroote School of Business in Hamilton, Ont. "On the other hand, you've got to know what you're buying. You can't assume that what you've bought or what you think you bought is what you actually did buy."
'No one says in these things that you can't have a drink. The problem is the magic word 'drunk', 'intoxication.'' - Marvin Ryder
And he said that reading through insurance policies is actually a lot easier than it was 30 or 40 years ago, when they were written by lawyers.
"Unless you had a law degree you wouldn't understand it," he said. "Today, though – 2017 – all these insurance companies have hired communication specialists to take the legalese, if you will, and try to translate it into more basic English so that people would understand."
'Drunk' is the problem
As a result, he said consumers are expected to read, understand and know what to expect from their insurance provider.
If your provider is CAA, that means your blood alcohol content can't be higher than 0.08 per cent, which is used as the criminal impairment level for drivers in Canada, although Ontario considers a level of 0.05 per cent as reason to take a driver off the road. Ryder said the limit may be different for other providers. And currently the federal government is consulting with Queen's Park to lower the impaired driving legal limit to 0.05 per cent.
"No one says in these things that you can't have a drink. The problem is the magic word 'drunk,' intoxication," he said. "If you're planning to get intoxicated – then you need to know that those actions could nullify your insurance."
And Ryder said that having alcohol in your blood could nullify your insurance claim even if your injury or sickness was not related to drinking.
'There's all those maybe, could-have, should-haves. So, that's why they've drawn this line this way. If your alcohol level is too high in your blood stream, your insurance is cancelled.' - Marvin Ryder
"In other words, if you have a heart attack while intoxicated, but the intoxication didn't cause the heart attack – nonetheless your insurance is null and void," he said.
The reason is that in medicine, it's hard to know what is a contributing factor. A person might trip, fall and end up in the hospital, but would the person have tripped if they had a lower blood alcohol level? Ryder said that's a difficult question to answer.
"There's all those maybe, could-have, should-haves. So, that's why they've drawn this line this way. If your alcohol level is too high in your blood stream, your insurance is cancelled."
CAA says claim is open, not denied
In theory, high alcohol in Ceres blood could give CAA cause to deny his insurance claim, but a spokesperson from the company told CBC News that the claim would be considered if alcohol was not the cause of the fall.
In fact, Director of Corporate Communications Tony Tsai said Ceres's claim had not been denied, but that it was still open.
"It really depends on what was the cause of the injury or what was the suspected cause of the injury," he said. "We're still waiting to get all that data back from them."
Although Ceres did have alcohol in his blood when he fell, Reis said doctors are suggesting that the fall was caused by pre-existing bleeding in his brain. If that was the case, it may be the information CAA needs to approve the claim.
In the meantime, Ceres remains in a New York hospital, where his expenses continue to accumulate. Reis said that the last she checked, the hospital bill had reached almost $100,000.