Support for Amendment of the Uniform Individual Accident and Sickness Policy Provision Law (UPPL)

The Uniform Accident and Sickness Policy Provision Law (UPPL) states "Intoxicants and Narcotics: The insurer shall not be liable for any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic unless administered on the advice of a physician."

The UPPL allows insurers to deny payment for treatment of alcohol-related injuries.

The UPPL was promulgated as a model law by the National Association of Insurance Commissioners in 1947, when treatment for alcohol problems was generally not available, and regional trauma and emergency medical centers did not exist.

Thirty-eight states and the District of Columbia adopted the UPPL in their insurance codes, and four states adopted provisional restrictions.²⁷

Physicians are less likely to screen patients for an alcohol problem in UPPL states because patients may be burdened by large medical bills.¹

In 2001 the National Association of Insurance Commissioners unanimously voted to repeal this provision of the UPPL and adopted a new model law that specifically eliminates this option from health insurance plans,² but only six states have adopted the amended model.

Injuries and substance use disorders are two of the leading public health problem in the United States,₃ with 35-50 percent of injured patients admitted to trauma centers being under the influence of alcohol or other drugs and 15-22 percent of emergency department patients with minor injuries having an alcohol-related problem.^4-7 Screening, brief intervention and/or referral to treatment (SBIRT) of injured patients who screen positive for an alcohol use disorder reduces subsequent alcohol intake, DUI, alcohol-related traffic infractions, alcohol-related arrests, injury-related hospital readmissions, and results in cost benefits.^8-18

A national survey of trauma surgeons’ alcohol screening practices documents that less than 15 percent of trauma patients are currently screened and offered counseling, and 27 percent of surgeons surveyed described the potential impact of screening on insurance reimbursement as a key reason for not screening.¹⁹

A variety of public policy, federal, expert and advocacy groups recommend routine alcohol screening and intervention for injured patients^20-24 and urge adoption of the 2002 amendment of the UPPL because the old model provided a significant barrier to provision of these services.²⁵

In jurisdictions where the UPPL is enforced, physicians have responded by not measuring or documenting alcohol use, thus causing insurers to pay for treatment of alcohol-related injuries, but often resulting in lack of screening and intervention.²⁶

Therefore APHA:

1. Calls upon state legislatures and state insurance commissioners to adopt the 2002 National Association of Insurance Commissioners UPPL amendment that prohibits insurers from denying reimbursement on the basis of patient intoxicant use; and
2. Calls upon state legislatures that did not adopt the original 1947 UPPL Model to pass a statute that specifically prohibits insurers from engaging in this practice.

References

1. Rivara FP, Tellefson S, Tesh E, Gentilello LM, Screening trauma patients for alcohol problems: Are insurance companies barriers? J Trauma Injury Infection Crit Care 2000;48:115-118. 
2. National Conference of Insurance Legislators. Resolution in support of amending the NAIC Uniform Accident and Sickness Policy Provision Law. Adopted by the NCOIL Health Insurance and Executive Committees, March 2, 2001.
3. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-2212.
4. Lowenstein SR, Weissberg M, Terry D. Alcohol intoxication, injuries, and dangerous behaviors-and the revolving emergency department door. J Trauma 1990;30:1252-1257.
5. Cherpitel CJ. Alcohol and violence-related injuries: an emergency room study. Addiction 1993;88:79-88.
6. Cherpitel CJ. Alcohol and injuries: a review of international emergency room studies. Addiction 1993;88:651-665.
7. Hingson RW. Heeren T, Zakocs RC, Kopstein A, Sechsler H. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24. J Stud Alcoho. 2002;63:136-144.
8. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA 1997;277:1039-1045.
9. Longabaugh, RH. Woolard RF, Nirenberg TD, Minugh AP, Becker B, Clifford PR, et al. Evaluating the effects of a brief motivational intervention for injured drinkers in the Emergency Department. J Stud Alcohol 2001;62:806-816.
10. Monti PM, Spirito A, Myers M, Colby SM, Barnett NP, Rohsenow DJ, et al. Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department. J Consulting Clin Psychol 1999;67:989-994.
11. Gentilello LM, Rivara, FP, Donovan DM, Jurkovich JG, Daranciang E, Dunn C, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg 1999;230:473-484.
12. Cherpitel CJ. Screening for alcohol problems in the emergency department. Ann Emerg Med 1995;26:158-166.
13. D’Onofrio G, Nadel ES, Degutis LC, Sullivan LM, Casper K, Bernstein E, et al. Improving emergency medicine residents’ approach to patients with alcohol problems: a controlled educational trial. Ann Emerg Med 2002;40:50-62.
14. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993;88:315-335.
15. Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med 1997;12:274-283.
16. WHO Brief Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers. Am J Public Health 1996;86:949-955.
17. Kunz MF, French M, Bazargan-Hejazi S. Cost effectiveness analysis of a brief intervention delivered to problem drinkers presenting at an inner city hospital emergency department. J Alcohol Studies In press.
18. Fleming MF, Mundt MP, French MT, Manwell LB, Staffacher EA, Barry KL. Brief physician advice for problem drinkers: Long-term efficacy and benefit-cost analysis. Alcoholism: Clinical and Experimental Research 2002;26:36-43.
19. Schermer CR, Gentilello LM, Hoyt DB, Moore EE, Moore JB, Royzycki GS, et al. National survey of trauma surgeons’ use of alcohol screening and brief intervention. J Trauma Injury Infection Crit Care 2003;55(5):849-856.
20. National Institute on Alcohol Abuse and Alcoholism. The physician’s guide to helping patients with alcohol problems. Washington, D.C.: Government Printing Office, 1995. (NIH publication no. 95-3769)
21. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, D.C.: National Academy Press, 1990.
22. Degutis LC. Screening for alcohol problems in emergency department patients with minor injury: results and recommendations for practice and policy. Contemp Drug Prob 1998;25:463-475.
23. Becker BM, Woolard RH, Longabaugh R, Minugh PA, Nirenberg TD, Clifford PR. Alcohol use among subcritically injured emergency department patients and injury as a motivator to reduce drinking. Acad Emerg Med 1995;2:784-790.
24. D’Onofrio G, Degutis L. Preventive care in the Emergency Department: Screening and brief intervention for alcohol problems in the ED: A systematic review. Acad Emerg Med 2002;9:627-638
25. Join Together. Ending discrimination against people with alcohol and drug problems: Recommendations from a national policy panel. Boston, MA: Join Together, Boston University School of Public Health, 2003.
26. Rachel Zimmerman. Why emergency rooms rarely test trauma patients for alcohol, drugs. Wall Street Journal February 26, 2003.
27. George Washington University. State statutes permitting insurance coverage exclusions for drug and alcohol related injury. Unpublished paper. Washington, DC: Ensuring Solutions to Alcohol Problems, George Washington University, 2003.

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