AD & D Claim Denied
Understanding AD&D Life Insurance Claims
An accidental death and dismemberment insurance (AD&D) or “double indemnity” policy is a special type of policy that may be purchased in addition to traditional life insurance. Typically, it’s sold as a rider or special addendum to a traditional policy. It may also be offered at work as a supplemental life insurance benefit to provide more financial security for an employee’s family in the event of unexpected accident.
As a breadwinner for your family, purchasing an AD&D insurance policy can be a smart way to protect your family if you’re no longer around. An AD&D insurance policy will pay benefits when the insured suffers an accidental death or dismemberment. In addition, those with extremely hazardous jobs may discover that their life insurance policy premiums are extremely high; but an Accidental Death and Dismemberment insurance policy might provide them protection at a more affordable price.
Also, an AD&D policy is different that workers’ compensation. That only covers work-related accidents. On the other hand, AD&D insurance applies wherever covered accidents happen—it could be in your home, your cabin, or while at a concert or sporting event.
An AD&D insurance policy will pay its proceeds to you or your beneficiaries (such as your family) in the event that your death or dismemberment is directly caused by an accident. AD&D benefits generally will not exceed a certain amount, and most insurance companies cap or limit the pay-out amount under these circumstances.
AD&D insurance pay-outs are usually the same amount as the face value of the original life insurance policy. Thus, the beneficiary gets a benefit twice the amount of the life insurance policy’s face value or “double indemnity” upon the accidental death or dismemberment of the insured.
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What Qualifies As An “Accidental Death”?
It’s important that you have a solid understanding the definition of an “accidental death” that’s typically used in AD&D policies.
An AD&D insurance policy is designed to cover deaths that happen by accidental means. The exact requirements may differ slightly among insurance companies. However, generally an accidental death not caused by war or due to an illegal activity will satisfy the insurer’s requirements for a policy to be paid to the beneficiaries. In order to be covered, an accidental death need not be instant, but it usually must happen within a certain time frame, such as within a few months. But note that some states, including Pennsylvania, do not permit an AD&D policy to have a requirement that death must happen within a specific time period.
A death that happens due to natural causes typically will not be covered even if death occurs suddenly, such as a heart attack, seizure, or aneurysm without some external triggering cause.
In addition, death by suicide or due to attempted suicide are usually excluded from coverage.
Accidental death typically covers exceptional circumstances like weather exposure, motor vehicle accidents, homicide, falls, death by drowning, and accidents involving construction equipment.
Read the definition in your application thoroughly so you know what circumstances qualify.
What is Dismemberment?
Under an Accidental Death and Dismemberment (AD&D) policy, dismemberment refers to the loss or severance of certain body parts or functions due to an accident. It provides coverage for specific injuries that result in the permanent loss of a body part or its function. The exact coverage and definitions may vary depending on the specific insurance policy, so it's important to refer to the policy document for precise details.
Typically, dismemberment coverage may include the loss or permanent severance of body parts such as limbs (e.g., arms, legs), hands, feet, fingers, toes, eyes, hearing, speech, or certain bodily functions. If the policyholder experiences such an injury due to an accident, they may be eligible for a benefit payment under the AD&D policy.
The benefit amount payable for dismemberment is usually a percentage of the policy's principal sum, which is the maximum benefit amount stated in the policy. The specific percentages assigned to different body parts or functions will be defined in the policy. For example, the loss of a hand might be compensated at a certain percentage of the principal sum, while the loss of a finger could have a lower percentage.
What Circumstances are Commonly Excluded from Coverage?
Every insurance company will stipulate the situations that are not covered as an accidental death. As mentioned above, the usual exceptions include suicide, death from illness or natural causes, and war-related injury.
Some policies also exclude death that is caused by drunk driving or use of illegal substances. In addition, an AD&D policy most likely won’t include a death from the following:
- Bungee jumping;
- Car racing;
- Death resulting from a mental or physical illness;
- Bacterial infection; or
Why Would The Insurer Deny A Claim?
There are a number of reasons why an insurance company may decide not pay an AD&D life insurance claim, including the following situations:
- A lapse in the policy because the owner of the policy failed to pay the premiums;
- Death while committing a crime;
- The murder of the insured by a beneficiary;
- Falsifying statements about income;
- Failing to disclose another existing life insurance policy;
- False answers on an application by an insurance agent;
- Failing to describe treatment for minor ailments;
- Lying about your weight;
- Lying about your immigration status;
- Failing to state that you smoke at least one cigarette a day; and
- Any other material misrepresentations on the application form, in the event that you die within the first two years of the policy
The last reason on this list was found to be the most common. Research by The Los Angeles Times of data from a few years ago showed that more than 65% of disputed claims concerned material misrepresentations, like not disclosing details of the applicant’s medical history.
However, most life insurance companies typically don’t dig for misrepresentations unless there’s a claim that somehow seems out of the ordinary. This is sometimes known as “post-claim underwriting” and means any mistake or deliberate lie on an insured’s AD&D insurance application may prove disastrous for his or her family if the insured passes away within the first two years of the policy. In most cases, the insurance company would return the premiums but wouldn’t pay out the death benefit.
In most states, an insurer can deny a claim even when the misrepresentation wasn’t related to the cause of death. A federal court held that an insurance contract can be considered void ab initio because of misrepresentations as to facts on the life insurance application that are unrelated to the cause of death. This means “to be treated as invalid from the outset” or as if there was no contract. If an insurance applicant commits any material fraud in his or her insurance application, the insurance contract may be void ab initio.
How Can I Make Sure That I Don’t Create Any Problems for My Family if They Need to Collect?
Our life insurance lawyers advise those considering an AD&D policy to be truthful and forthright on the application. Although you may fudge an answer to get a better premium price, this may cost your family if the insurance company believes that you falsified your answers in procuring the policy.
There are several actions you can take to reduce the risk that your family’s AD&D life insurance claim will be questioned or denied after your gone:
Be Honest on Your AD&D Life Insurance Application. Again, it may be tempting to try to conveniently overlook your college smoking habit, your use of alcohol (even if it’s moderate), your previous treatment for depression, or your love of skydiving in your AD&D life insurance application. You may think you’re clever when the application is approved. However, if you die within the first two years of the policy, the company may discover that misrepresentation about your days on the NASCAR circuit, and rescind the policy. And they can do this despite the fact that you haven’t done any race car driving in 20 years, and it had nothing to do with your death. That lie will come back to haunt you…or more precisely to haunt your family, who were counting on the insurance proceeds to help them in the future.
Take Plenty of Time in Answering the Questionnaire. Carefully consider all the questions on the application. Life insurance applications can be lengthy and complex, and you might want to just automatically check “no” down a long list of symptom or diseases. But there may be one in that list that you should have checked “yes.” Again, that rush to finish—even if it’s a simple mistake or misunderstanding—could cancel your policy and leave your family unprotected in the event of your death.
Mistakes are made when applicants quickly fly through the medical questions. For example, many folks forget to mention their smoking habits.
If You Don’t Understand a Question or Term, Ask for Help. It’s okay to tell your agent that you have a question or that you don’t understand what the insurance company wants on an answer. It’s better to ask first than to have to do some embarrassing explaining when your application comes back from the underwriters. Underwriting is the insurance company’s research and investigation division that verifies that the information you put on your application is correct. The insurance company would like to know that you failed to mention that you’ve been in and out of the hospital for the past 12 months for various maladies now instead of after the insurance is in effect or when your family tries to collect after your sudden death. The underwriters are trying to assess your level of risk before assuming that risk. This research helps the insurance company establish appropriate premiums to sufficiently cover the true cost of insuring you. Your level of risk— and the corresponding premium you’re asked to pay will be different if you engage in risky activities like bungee jumping versus spending all your free time working on your stamp collection.
Review Your Application Thoroughly. After you complete your AD&D insurance application, carefully review it to make certain that all the answers and information is accurate before signing it.
What Can I Do If The Insurer Denies A Claim?
If you’re a beneficiary whose AD&D claim is denied, you need to speak with an experienced insurance attorney from our firm. From our extensive experience, we know that the insurance company’s reason for the denial may not be a material misrepresentation that should result in rescinding a policy.
We can help you evaluate your situation and assist you in the successful appeal of the insurance company’s decision to deny your claim.
If you have a personal AD&D policy, state insurance and contract laws apply. Again, for example, insurance law states that a provision for accidental death benefit may not contain a requirement that death must occur within a specific time period.
In a non-ERISA appeal, you and your insurance attorney may file a lawsuit right away and demand a jury trial. You may be able to ask for punitive damages if it’s found that the insurance company denied your claim in bad faith.
Remember that the court has specific filing deadlines, and if you fail to initiate your action before the deadline or statute of limitations, your claim will be dismissed. It’s best to contact a knowledgeable insurance attorney to help you prepare your case and to represent your interests against the insurance company.
Remember that AD&D insurance is not substitute for life insurance because an AD&D policy is very specific as to the types of death that it covers. A traditional life insurance policy, like a 10-year term life insurance policy, doesn't cover injuries that aren't fatal, such as the lost of hearing or the loss of the use of your arms.
AD&D insurance is a complicated, industry-driven area of insurance. There are instances when a sudden and unexpected death may not qualify for benefits. If you have questions about an AD&D policy, contact us.
Accidental death and dismemberment (AD&D) insurance is frequently offered as an employment benefit by employers. You can also buy a standalone AD&D by itself, but more commonly, it’s offered as a supplement insurance or insurance policy benefit rider. In the most simple terms, AD&D insurance pays benefits when the insured is either killed or loses a limb, vision, or hearing in an accident. If you survive, the applicable amount of the policy will be paid to you. This is called “living benefits.” If you die, the policy will be paid to your beneficiaries. Payments are usually paid in a lump sum.
When AD&D Insurance is offered as an employment benefit, the amount will be specified by your employer, and may be based on your salary. A benefit could be $25,000, $100,000, $200,000. It will depend on your employer. There is no medical underwriting component required. You may be able to purchase supplemental AD&D insurance to the standard benefit for a very low amount. For example, a $10,000 benefit to cover your spouse might be $0.08 per paycheck. These policies are inexpensive because statistically, the odds of you using them are low. It should also be noted that coverage in an employer-offered group plan AD&D policy will likely terminate if you leave your job.
What Can You Use AD&D Insurance For?
AD&D insurance benefits can be used just like insurance benefits, to cover expenses after a family member’s loss, as well as cover their existing debts at the time of their death. You can use an AD&D policy payout for anything you need it for. Some of the things people use life and AD&D Benefits for are:
- Funeral expenses
- Remainder of mortgage
- Credit card and auto loan debts
- Student loan debts
- Living expenses
- Purchasing a home.
If you are injured, for example, paralyzed in a car accident, the “living benefits” portion of an AD&D policy can be paid out whereas standard life insurance benefits would not be.
How Much is Paid out in an AD&D Benefit (Loss of Life or Living Benefits)
Below is a sample schedule for an AD&D Insurance Benefit. The amount payable is a percentage of the AD&D Insurance Benefit amount in effect on the date of the accident and is determined by the loss suffered as shown below:
a. Loss of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100%
b. Loss of one hand or one foot . . . . . . . . . . . . . . . 50%
c. Loss of sight in one eye, speech, or hearing in both ears . . . . . . . . . . . . . . . 50%
d. Loss of two or more of the losses listed in b. and c. above . . . . . . . . . . . . . 100%
e. Loss of thumb and index finger of the same hand, or loss of hearing in one ear . . 25%*
f. Quadriplegia . . . . . . . . . . . . . . . . . . . . . . 100%
g. Hemiplegia . . . . . . . . . . . . . . . . . . . . . . . . 50%
h. Paraplegia . . . . . . . . . . . . . . . . . . . . . . . . . 75%
i. Coma. . . .1% per month of the remainder of the AD&D Insurance Benefit payable for Loss of life after reduction by any AD&D Insurance Benefit paid for any other Loss as a result of the same accident. Payments for coma will not exceed a maximum of 100 months. No more than 100% of your AD&D Insurance will be paid for all Losses resulting from one accident.
Note: For living benefits, no more than 100% of your AD&D Insurance will be paid for all Losses resulting from one accident. For example, if you lose your hand, you cannot also claim you lost your thumb and index finger.
Common Exclusions to an AD&D Policy
It is important to understand that AD&D Insurance is extremely limited in what it covers. It only covers you if you are in an accident. Even if a sudden and unexpected accident occurs, if the accident is caused by a specifically excluded event, the claim may be denied or contested. A seemingly simple policy may, in reality, become complex and subject to interpretation and dispute. Even the name of the policy “Accidental Death and Dismemberment” seems to imply that any event within those categories would be covered. However, this is not the case, and there are many exclusions that relieve insurance companies of their payout obligations. Examples of injury or “accident” losses that may be specifically excluded from an AD&D policy:
- Accidents occurring while committing or trying to commit a felony
- Accidents occurring while drinking and driving
- Accidents occurring while skydiving or flying in an ultra-light glider
- Accidents occurring while car racing (as driver or passenger)
- Accidents occurring while attempting to commit suicide
- Accidents occurring as a result of a drug overdose.
The Sickness Exclusion in AD&D Policies
The sickness exclusion in an Accidental Death and Dismemberment (AD&D) policy refers to a provision that excludes coverage for injuries or deaths resulting from sickness or disease. Unlike accidents, which are sudden and unexpected events, sickness or disease is considered a non-accidental cause. AD&D policies are specifically designed to cover accidental injuries or deaths, and they typically exclude coverage for losses caused by sickness or disease.
Here are some key points regarding the sickness exclusion in AD&D policies:
Scope of exclusion: The exclusion applies to injuries, disabilities, or deaths that directly result from sickness or disease. It typically encompasses both physical and mental illnesses.
Examples of excluded events: Under the sickness exclusion, if a policyholder dies or becomes disabled due to a medical condition such as a heart attack, stroke, cancer, infection, or any other illness, the policy would not provide coverage.
Accidental coverage focus: AD&D policies are primarily focused on providing coverage for sudden, accidental events, such as injuries resulting from accidents, falls, motor vehicle collisions, or other unforeseen incidents.
Exceptions: While sickness and disease are generally excluded, there may be some limited exceptions depending on the policy. For instance, some policies might include a "double indemnity" clause, which provides coverage if the insured's death is a direct result of an accident, even if sickness or disease contributed to the accident. However, these exceptions are typically specified explicitly in the policy and may have specific conditions or limitations.
Clear definition of terms: AD&D policies usually have clear definitions of what constitutes an accident and what qualifies as sickness or disease. It's essential to carefully read and understand these definitions to grasp the scope of coverage and exclusions.
Complementary health insurance: AD&D policies are typically not meant to replace comprehensive health insurance coverage, which is specifically designed to cover medical expenses resulting from sickness or disease. AD&D coverage is more focused on providing additional financial protection in the event of accidental injuries or death.
To obtain precise information about the sickness exclusion and other policy details, it's important to review the specific terms and conditions of the AD&D policy offered by the insurance provider.
Denial Based on Filing Time
It is possible that an AD&D benefit may be denied based on failure to file a claim within a certain period of time. In some cases, filing deadlines for an AD&D policy may be different than a standard life insurance policy. If your policy is an employer-funded AD&D insurance plan, the Employee Retirement Insurance Security Act (ERISA) applies. This is a federal law which will preempt state laws. The process for appealing may be different as well. If you have questions, it’s best to speak with a lawyer as soon as possible.
It is extremely common for people to have preexisting conditions like obesity, diabetes, hypertension and high cholesterol. Having these conditions or taking medications for them should not exclude you from policy coverage. However, when a claim is made, insurance companies and courts will look at these and whether they proximately caused or substantially contributed to an accidental death. The language of the insurance policy will be carefully reviewed, especially in regards to words like pre-existing conditions, proximate, predominant, and substantially contributing causes. Courts have had to look at unlikely chains of events in making determinations of what is an accident.
Sometimes the most unlikely scenarios lead to complex life insurance claim disputes. Huff v. Aetna Life Ins. Co. is one example of a chain of events creating questions of proximate and indirect causes of accidents. James Huff suffered a heart attack and lost control of his vehicle in Arizona on September 9, 1973. The force of the collision broke one of Mr. Huff's ribs and caused the rib to perforate his heart, causing his instant death. The argument was made that Mr. Huff was alive until the rib perforated his heart. The court was asked to determine whether the language of Aetna's exclusionary clause is sufficient to prevent the insurance payment when the "disease or bodily infirmity" (in this case Mr. Huff’s heart attack). The court ultimately ruled in favor of Aetna in regards to the determination of accidental death. An important note, in a situation where an AD&D claim is unfortunately denied, policy benefits may still be available for standard term life insurance.
Accidental Death From Exposure
Accidental deaths have been disputed for years, and courts have very closely analyzed how they differ from deaths resulting from accidental causes, specifically whether insurance policies must pay output policies for them. A couple historical examples from the archives present unique scenarios:
- Freezing to Death: Ashley v. Agr. Life Ins. Co., etc., 241 Mich. 441, 217 N.W. 27, 58 A. L. R. 1208, Harold Ashley became lost while hunting deer in Michigan, wandered into a swamp and froze to death on a log. The judge found “Insured's becoming lost was not by design, volition, or intent. It was not an expected or usual incident of hunting. It was unusual and unexpected, fortuitous. He became lost accidentally. “ In this case, freezing to death was not an accident, but the accidental exposure to the storm was, and the court ruled in favor of the payout.
- Sunstroke: Nickman v. New York Life Ins. Co. 39 F.2d 763 (1930). 50-year-old Nickman died of sunstroke after a busy day running errands and having an argument on a roof. The insurance company denied the accidental death claim. The judge ruled in favor of the insurance company, with the judge concluding there no substantial evidence that such injury was effected through accidental cause. He further concluded there was “much controversy over whether sunstroke is a disease, or is to be classed as bodily injury effected through violent and external means.”
AD&D policies and exclusions can be complex. It is always a good idea to have an attorney review any denied life insurance claim, as soon as possible and before responding or filing any appeal.
AD&D Payout Delays
Insurance companies are contractually required to pay you out within a specified time, usually within 30 to 60 days of an accidental death. This does not happen often, in reality. The insurance company will probably tell you they need more time to investigate and make their determination if a death is accidental. They may claim the death from a solo-vehicle car accident was a suicide or resulted from a health event or another non-covered AD&D clause, even if there is no evidence to support that. To add further insult, they may put it on you to prove your loved one’s death really was a covered event. If you’re getting any type of insurance denials, delays or runaround, it’s time to speak with an attorney.
AD&D policies have limitations, and there can be grey areas. Insurance companies will deny claims if they believe the death is not covered under the terms of the policy. Fortunately, you do have options to fight a denial. As attorneys who handle life insurance claim denials, sometimes we have to tell people that there is simply nothing that can be done. However, there are many, many cases where the insurance company has said “NO” and we have successfully been able to not take no for an answer.
Your time to fight a denied insurance claim is very limited. If you are dealing with a denied AD&D insurance claim, call us as soon as possible for a free consultation. We can be reached seven days a week, or fill out our contact form and we will contact you to discuss your case. If we believe we can help you, we will do everything we can to ensure you receive the benefits to which you are entitled.
Accidents happen, and when they do the last thing you want to worry about is a denied AD&D claim. Although some forms of life insurance policies include stipulations regarding accidents that lead to death or serious injury, most do not. For that reason, many individuals opt to include Accidental Death and Dismemberment (AD&D) insurance as a rider or separate policy to keep their loved ones protected.
What is AD&D insurance?
AD&D is a common form of rider insurance added to a more holistic life or health insurance plan. AD&D insurance covers unintentional death or dismemberment. The dismemberment clause typically covers the loss of or functioning of sense organs such as sight, hearing, or speech in addition to limbs.
AD&D policies are known for providing double or even triple indemnity. This implies that beneficiaries of an AD&D policy may receive double or triple what a typical life insurance policy would provide.
However, AD&D insurance only covers the most unlikely scenarios. This makes it vital to understand what qualifies as an accidental death or accidental dismemberment in your policy. Generally speaking, for a claim to qualify for AD&D insurance, it must be proven that the accident was in fact an accident uncaused by the policyholder and that injuries or death were a direct result of that accident.
Commonly covered accidents include:
Death or injury resulting from a vehicular accident (under certain conditions)
Death or injury from exposure to harmful elements
Death or injury from slipping or falling
Death or injury from equipment and machinery
Accidents resulting from murder attempts
Reasons for a denied AD&D claim
To understand what qualifies as AD&D insurance, it can be helpful to understand what is excluded by AD&D insurance. The following are typically excluded in AD&D coverage:
Death or injury during a surgery, whether an emergency or elective
Death or injury resulting from a suicide attempt
Death or injury resulting from a physical or mental disability
Death or injury from a bacterial infection such as the common cold, the flu, or even COVID-19
Death or injury resulting from a hernia, heart attack, stroke, prescribed medication
Death or injury from a drug or alcohol overdose
Death or injury from skydiving, car racing, drunk driving, or other extreme endeavors
Death or injury resulting from war or acts of war
Death or injury resulting from illegal activities
Death or injury from illegal activities is a sort of blanket clause included to protect insurance providers. For example, if you are out hiking, the rules of the park will likely require you to stay on the trail. If you venture off the trail to look over a cliff and end up slipping and falling 80 feet and either die or seriously injure yourself, your AD&D coverage will likely not cover your claim. Even if the act of slipping is considered an ‘accident’, the act of venturing off the trail will void your claim.
In almost every case it boils down to what qualifies as an ‘accident’. No two policies are the same and no two insurance providers have the same stipulations. This makes it important to read the fine print before signing an AD&D claim to fully understand what is being covered. And, it makes it equally as important to read the fine print afterwards to see if you have a rightful claim.
Many of the above reasons can still be denied in bad faith. Unless the accident is explicitly highlighted in your policy, your insurance provider might be falsifying the reasons for their claim.
How to handle a denied AD&D claim
If your AD&D claim has been denied, the first thing you need to consider is whether or not it was done so in bad faith. This may not be easy for the person filing the claim to do himself or herself. They may not have all the facts and are likely to be a bit biased in their assessment.
For example, let’s say a policyowner was struck by a car while stopped at a red light and the crash resulted in her death. It may seem obvious to her beneficiaries that the crash was, in fact, an accident. She was following the rules of the road when the worst possible scenario occurred. However, the autopsy reported that she had alcohol and marijuana in her system. How does this complicate the situation? Are car accidents included in the AD&D policy or not? And does the presence of alcohol and marijuana in the policyowner’s system affect the situation? How much is too much? What if she was below the legal limit and the traces of marijuana were days old?
It might still seem obvious to the beneficiaries that their claim was denied in bad faith. Or, it may seem obvious to some beneficiaries that the details of the situation do, in fact, negate the claim.
However, when it comes to insurance claims, the answers are usually not so crystal clear. There is a lot of fine print and ambiguous terminology that can radically change the outcome.
For this reason, working with an experienced life insurance lawyer before filing your appeal can make a major difference. A legal expert will be able to decipher the terminology and make sense of the specific AD&D policy.
Legal experts will also be able to investigate the accident reports including medical records, toxicology reports, coroner’s reports, death certificates, and eyewitness testimony. They are also able to review similar cases to your own to see how they were handled in both state and federal courts in the past.
They can even hire medical professionals or accident reconstructionists for expert testimony in your case. When it comes time to file the appeal, a legal expert will ensure you have adequate amounts of data, evidence, and testimony to get your AD&D overturned.
In addition, insurance companies may refuse to pay benefits for accidental death insurance claims by claiming that the death was not the result of an accident or that it was not independent of all other causes. These terms are often ambiguous and are hard to decipher for anyone who is not versed in legalese or insurance terminology, especially if a policy does not define these terms. Insurance companies may deny AD&D for the following reasons:
Self-Inflicted Injury: The insurer may claim that the insured deliberately caused his/her own death. It can claim that the death was a suicide, and may send a beneficiary a denial letter stating that it is the beneficiary's burden to prove otherwise. The law, however, is against presumption of murder and suicide, and will often require the insurance company to produce sufficient evidence in support of its claim of suicide.
Recklessness: The insurer may claim that the death was caused by the insured's own recklessness and is, therefore, not covered. Risky hobbies such as parachuting, mountain skiing, or rock climbing may cause the insurance company to refuse to pay the beneficiary.
Illness: The insurer may claim that the person died due to an illness. This type of a denial is very common in falling accidents, where the insured falls, sustains a bodily injury that results in other health complications or that exacerbates the insured's already existing medical conditions.
Delay between the accident and death: The insurer may claim that due to a lapse of a long period of time between the accident and the death, the death is not covered. If a person was severely injured in a car crash and never recovered from the injuries which subsequently lead to his/her death, the insurance company may refuse to pay accidental death benefits because the death did not follow immediately after the accident.
Prescription Drug Abuse: Insurance companies often deny valid claims by relying on their own medical experts who often misinterpret toxicology reports and state that the insured had an elevated level of a prescription drug, and, therefore, the death is not a covered loss.
We are a team of professional legal experts in the life insurance industry. We understand that our clients go through grieving coupled with financial problems. We offer compassionate, competent advice and aggressive representation of our clients' interests. If you need help figuring out the denial of your AD&D claim, call us for a free consultation. We will answer all your questions and will try to help you resolve your issues. Our attorneys at can get you the death benefits you deserve, and we will fight the insurer for the full amount from your accidental death claim. Contact us today for a free consultation on your case.
Stonebridge Company recently settled our client's claim for its refusal to pay accidental death benefits. Our clients were beneficiaries covered under an accidental death and dismemberment policy of insurance issued to the insured. After an accidental death of the insured, they came to us to make a claim for benefits. Stonebridge Life Insurance Company had initially denied their claim stating that the death was not an accident. We alleged breach of contract and bad faith insurance practices in our 200 page legal brief. Our AD&D claim lawyers got them the full policy along with interest.
How Can I Get My ADD Benefits?
Accidental Death & Dismemberment insurance provides a lump sum payment to the beneficiaries if the insured dies as the direct result of an accident or if he/she loses a portion of the body because of an accident. Often, people have both - life insurance and AD&D so if the insured dies in an accident, both benefits will be paid to the beneficiaries. If the insured is covered under AD&D and loses a portion of his body as the result of an accident, then the insured himself will be the beneficiary of the claim.
When a valid claim for AD&D benefits gets denied by the insurance company, the beneficiary may be looking for answers. There are two main reasons why the insurers deny such claims. First, they may claim that the death is not covered by the policy, meaning that the death was not an accident. Second, even if the death is an accident, the insurance company may claim that an exclusion applies and excepts the death from coverage. AD&D policies may be difficult to construe and exclusions may be ambiguous and written with the intent to be applied to many different scenarios. It is for this reason that you need to consult with a life insurance attorney. Our life insurance attorneys know how courts look at the ambiguous language in life insurance policies and how such language gets construed.
Unfortunately, many beneficiaries give up when they receive a denial letter from the insurer elaborately explaining why their AD&D claim is being denied. The loss of a loved one coupled with the frustration over dealing with the insurance company may exhaust the beneficiary and lead to the acceptance of the unfair outcome. However, every delay and denial is appealable. We urge you to give us a call and let our experienced aggressive lawyers handle your claim for you.
Never accept the insurance company's denial of your AD&D claim without a fight. You can get the denial reversed by hiring a competent life insurance attorney whose main focus is on this type of law. At our firm, we handle many different cases of life insurance delays denials and will give you a free consultation if your claim is unfairly handled.
Accidental Death & AD&D Life Insurance Claim
According to statistics, accidental deaths are the fifth leading cause of death in the United States. Many of us prefer to add accidental death coverage to a regular life insurance plan. What exactly accidental death covers may be not so easy to determine. Generally, accidental death insurance will pay benefits in the event of an accidental death. It can be paid in addition to any other life insurance. In many instances, the accidental life insurance can be an add-on to a regular life insurance plan.
Typical covered accidents:
- car or truck crash
- exposure to elements
- slip trip or falls
- equipment accidents
Accidental death insurance has many exclusions and every insurer usually maintains a list of events and circumstances that void the insured's entitlement to his or her accidental death benefit. For example, death by illness, suicide, non-commercial radiation, war injury and natural causes are generally not covered by this type of insurance. Many insurance companies will deny an accidental death claim if the insured died while under the influence of any non-prescribed drugs or alcohol or overdosed with toxic or poisonous substances. Injuries of an athlete received in a professional sporting event may also void the claim. These common exclusions make it extremely difficult for beneficiaries to receive benefits. The process of claiming the benefit may be delayed due to investigation.
Four common types of group accidental death insurance plans offered in the United States are:
Group Life Supplement - the AD&D benefit is included as part of a group life insurance contract, and the benefit amount is usually the same as that of the group life benefit;
Voluntary - the AD&D is offered to members of a group as a separate, elective benefit,
Accident While Traveling- the AD&D benefit is provided through an employee benefit plan and provides supplemental accident protection to workers while they are traveling on company business (the entire premium is usually paid by the employer);
Dependents – Some group AD&D plans may provide benefits for dependents.
Should I Buy an Accidental Death Insurance?
According to the Centers for Disease Control and Prevention, 121,599 people died from unintentional injuries in 2006. A 2009 National Center for Health Statistics report says that age is also a factor in the leading causes of death. If you are a 35-year-old nonsmoking male, you are four times likely to die in an accident before age 45 as you are to die from heart disease. If you are a woman of the same age, you're twice as likely to die in an accident than from breast cancer. The main killers in the US are heart disease (204.1), malignant neoplasms (cancer, 185.7) and cerebrovascular diseases (such as diabetes, 44.4). People 45 and older are more likely to die from natural causes than from an accident according to the NCHS report.
If you have lost a loved one in an accident, please call our life insurance attorneys for help with your life insurance claim.
Grief following the death of a loved one is overwhelming in itself, but add a denied claim, and it can be overwhelming. Our life insurance claim denial attorneys encourage beneficiaries whose claims have been denied to stand up and fight the insurance companies for payment of death benefits bought and paid for by the deceased in a life insurance policy. Insurance companies will look for every excuse to deny death benefits to beneficiaries:
Cause of death — Our life insurance lawyers represented the family of a person who had a rare medical condition, who died of a seizure aboard a commercial carrier. The policy language covered only death by "natural causes". The insurer claimed the cause was "accidental death" brought on by the surrounding circumstances. After our legal team found that this same issue had been decided against an insurance carrier in a similar case the insurer paid the claim.
Incontestability — An insurance company may deny life insurance claims because of omitted facts or misstated information on the application for insurance. Our firm argues incontestability if the information was provided in good faith and the carrier continued to collect premiums for several years without noticing the errors. They must prove fraud.
Pre-existing Conditions — A common default which insurance companies try to say there was some condition which wasn't disclosed, but we can get over this hurdle.
Insurance companies have very little sympathy for policy beneficiaries and are inclined to deny claims if they can think of any kind of excuse to do so. And, you can be sure they are very good at dreaming. Our attorneys do care for people, and we fight hard to secure the life insurance benefits clients desperately need. Our attorneys promptly return phone calls and take the time to examine your policy and explain your rights. Contact our insurance attorneys for an experienced examination of your policy language and the merits of your case.
Often, beneficiaries are denied benefits because the insurance company claims the decedent was intoxicated at the time of death. A close look at federal common law, however, shows that it is not always the case. Many courts rules that intoxication status of the insured needs to be the cause of the accident in order for the benefits to be denied. The case below is a recent federal court case discussing the issue.
In Papotto v. Hartford Life & Accident Ins. Co., plaintiff, the widow of the insured, was denied accidental death and dismemberment ("AD&D") benefits after her husband's death. The decedent was employed by TD Banknorth and participated in an ERISA-qualified group benefit plan, which provided him with an AD&D policy. The Policy excluded from its coverage any loss caused or contributed to by injury sustained while intoxicated. The policy defined intoxication as when blood alcohol content or the result of other means of testing blood alcohol level meet or exceed the legal presumption of intoxication, or under the influence, under the law of the state where the accident occurred.
On the day of his death, the husband was playing golf and consuming alcohol when he fell out of a golf cart while reaching for a cell phone he had dropped, struck his head, and died five hours later. A subsequent toxicology report showed he had a blood alcohol level of .115 grams per deciliter.
Under the policy, the widow filed a claim. That claim was denied by the insurance company based on its exclusion of injuries that occur while intoxicated and the husband's blood alcohol level exceeding the state's standard for driving while intoxicated: 0.08 grams per deciliter.
The court held that federal common law will be applied to the interpretation of ERISA benefit plan provisions. The court also held that it is proper to imply a causation requirement to a status based intoxication exclusion and found that the administrator's interpretation of the word intoxication was unreasonable. The court said that the unreasonableness of such interpretation was best demonstrated by the hypothetical: under the insurance company's interpretation, an intoxicated individual fatally struck by lightning while safely relaxing in the comfort of his home would be denied coverage.
The court also stated that the carrier's interpretation was not consistent with the reasonable expectations doctrine, a doctrine applicable to interpretation of ERISA-governed insurance contracts. The reasonable expectations doctrine protects the reasonable expectations of applicants, insured, and intended beneficiaries regarding the coverage afforded by insurance carriers even though a careful examination of the policy provisions indicates that such expectations are contrary to the expressed intention of the insurer.
Our firm has had success 100% of the time on AD&D claims, and we have handled over a thousand. Call our life insurance attorneys today.
AD&D insurance pays benefits to the beneficiary if the death of the insured was the result of an accident. Many people buy this type of insurance as an addition to the regular life insurance. Covered accidents include motor vehicle accidents, accidental shootings, homicides, falling accidents, work accidents and drowning. However, insurance companies deny AD&D claims if the death falls outside their definition of an accident. In addition there are exclusions that apply to accidental death. Thus, if an insured died as a result of an illness, suicide, war injury, self-inflicted injury or complications of an existing condition, the company may rescind the policy and refuse to pay AD&D benefits. Overdose with legal and illegal drugs, toxic and poisonous substances may also void the right to a claim.
In addition to claiming that the death fell outside the policy definition of accidental death, insurance companies often refuse to pay AD&D claims if an exclusion applies to the accidental death. One of the most common exclusions is intoxication. If the insured died as a result of an accident, but the toxicology report revealed controlled substances, alcohol, illegal drugs or legal drugs taken over the prescribed limit, the insurance company most likely will deny the claim. A beneficiary whose loved one died as a result of an accident can increase his chances of having the claim paid by hiring a life insurance attorney before filing a claim for AD&D benefits. If your AD&D claim is delayed and the toxicology report showed presence of any substances mentioned above, call a life insurance attorney for help. When we get involved in a delayed life insurance claim case, we make sure the claim is being handled properly and the rights of the beneficiary are protected.
In early 2013, our life insurance attorneys were successful in reversing a denial of an AD&D claim where the decedent-insured died in a car accident, but the toxicology report showed that blood alcohol was over the state legal limit. We proved to the insurance company that the cause of the accident was not the insured's alleged intoxication, but a tire blowout, showing that the average person with no alcohol in the blood would not have been able to prevent the accident or leave the overturned vehicle after the accident. In addition, we always carefully study medical and investigative records: toxicology reports, police reports, records from the office of the medical examiner and coroner's reports. We make sure that these reports reflect accurate information and that the methods of collecting blood samples are properly administered according to the state law.
Vast experience in investigating AD&D claims and circumstances surrounding the death of the insureds sets our life insurance attorneys apart from other lawyers. We sincerely care about our clients and provide compassionate, professional services you deserve. If your AD&D claim is being delayed, act now and do not let it get denied. Call us now for a free consultation.
When a loved one dies unexpectedly, surviving family members deal not only with the emotional trauma, but also with the financial difficulties associated with the loss. If the decedent carried accidental death insurance, you should file a claim for accidental death benefits. If the person died at work, depending on the events surrounding the death, the employer may also be liable for additional compensation. While many regular life insurance policies will cover accidental death, a separate accidental death benefit is often an optional benefit or "rider" on the policy. Many life insurance policies include a clause paying double or triple in the case of accidental death. If you have an AD&D Claim, our lawyers can help.
Reasons AD&D Claims Are Denied
Often AD&D claims are delayed, because the insurer is making a decision based on the economic facts rather than the facts of the claim. Many insurance companies provide AD&D coverage for a very small premium because they know that few persons die from accidental causes. Therefore, they are not making the profit they are seeking without delaying and denying many of the claims. Statistics show that U.S. insurance companies hold accidental death polices valued at nearly $7.7 trillion dollars which earns them $25 million in annual revenue. So, the stakes involved are huge when it comes to insurance company profitability. Due to dishonest insurance practices in accidental death claims administration, several insurers have been investigated by attorney general offices in several states and fined millions of dollars.
Why You Need a Denied AD&D Claim Attorney
ERISA cases are very tricky, and complex. The insurer only has the policy amount to lose. This is the reason many companies take the risk and deny the claim. Even if the beneficiary appeals, the case may be denied forever as most people will not get the experienced counsel required to submit a winning appeal. Many clients make a mistake by submitting an appeal that offers very little support for payment. Afterwards, no new evidence will be allowed, the claim file will be closed, and the case may be lost even before a lawsuit can be filed.
The insurers also base their denials of AD&D claims by trying to use exclusions in the accidental death policy. One of their favorites is the self-inflicted death exclusion for persons involved in automobile accidents. If the insurer can find any evidence of negligent or intoxicated driving, they will try to pin this exclusion on the case and deny coverage. The problem is that in many cases it is not supported in fact or law. Another reason for delay is a death exclusion in which a person must die within a year of the accident to be covered. An example of this is a case when an insured gets seriously injured in an accident, but lives for more than a year.
Not many attorneys understand the complexities of life insurance and ERISA law. Our life insurance law firm has the experience and skill you can trust. If your AD&D claim is delayed for more than 30 days, call us for help. Not only will our lawyer s determine whether the insurance company is liable for death benefits, but we may also determine if you have a right to pursue a wrongful death claim.
Why Insurance Companies Deny AD&D Claims
Accidental Death and Dismemberment (AD&D) insurance policy provides coverage for death resulting from an accident. Many AD&D claims are denied because insurance companies determine that the death was not a result of an accident. It is important to know the definition of the word accident as it is defined in the Policy. The definition of "accident" can usually be found in the policy under Section "Definitions". The most common definition of "accident" is "an unforeseeable, forceful, external event." In addition, many courts differentiate between death caused by an accident and death caused by accidental means. When the policy does not define "accident," courts will use its plain and ordinary meaning.
Even if the death is deemed to be accidental on the Death Certificate and Medical Examiner's report, the insurer can still deny your AD&D claim. The reason for that is the application of many exclusions that usually appear in the AD&D contract. Some of the most popular AD&D exclusions include:
- Sickness exclusion
- Prescription drug misuse
- Illegal drug use
- Death not independent from other causes
- Participating in a crime
Moreover, an AD&D claim is likely to be denied if the death occurs 365 or more days after the accident. If your AD&D claim has been denied, it is always a good idea to consult a life insurance attorney who will examine the facts of the case and will advise you as to whether the claim has been wrongfully denied. AD&D claims are confusing and the language in the policy may be too complex for a beneficiary to understand. AD&D attorneys at our firm know how to dispute a wrongful denial and understand what it takes to collect the life insurance proceeds. All AD&D cases are very fact-specific and usually involve complex laws and policy language construction. If your accidental death and dismemberment claim has been denied or delayed, contact us for a free case evaluation.
In a recent ERISA case, the court denied benefits to the widow of a decedent who suffered a fatal allergic reaction to a bee sting. The decedent was insured under an employee welfare benefits plan governed by ERISA that excluded coverage for losses contributed to or caused by disease or physical impairment. The district court held that the insurer properly denied coverage based on this exclusion. If you have an AD&D claim, our life insurance lawyers can help.
The insured was stung by a bee on this nose, and died. The life insurance company denied the benefits.
The exclusion in the AD&D policy read, "Benefits under the AD&D section of the Plan are not paid for losses contributed to or caused by: Disease or medical or surgical treatment of such disease; intentionally self-inflicted injury; physical or mental impairment or medical or surgical treatment of such impairment…"
MetLife denied benefits based on this exclusion. The widow appealed the denial, arguing that there was no evidence that an allergy was a contributing cause of the decedent's death--only evidence that the decedent died as a result of being stung on the bridge of his nose. Hall also argued that even if the decedent had a pre-existing sensitivity or allergy to bee stings, this condition was not a "disease" or "impairment." Hall further argued that when an injury activates a dormant disease, the injury should be held to be the direct and exclusive legal cause of death, thereby allowing her to recover. MetLife found the widow's assertion regarding causation to be contrary to the uncontroverted medical evidence and reiterated its earlier conclusion that the decedent's bee-sting allergy was a disease and a physical impairment that contributed to or caused his death.
The widow initiated a court action. The court affirmed the denial of the AD&D claim on appeal based on a two-prong test: (1) whether there was a preexisting disease, predisposition, or susceptibility to injury; and (2) if so, whether the preexisting disease, predisposition, or susceptibility to injury substantially contributed to the disability or loss. The court held that the decedent's bee-sting allergy was properly viewed as a preexisting disease, predisposition, or susceptibility to injury based on an independent consulting physician's report, and was thus unambiguously excluded from coverage by the plan.
If you are the primary provider for your household, protecting your loved ones with an accidental death and dismemberment (AD&D) life insurance policy is a wise investment. Burdening those you love with financial responsibilities and unexpected funeral costs is not a circumstance you want them to ever worry about when you pass. Unfortunately, it is still possible their claim could get denied under certain scenarios.
AD&D life insurance policy is a rider that you can purchase as a supplement to your traditional coverage. Many employers offer these to their employees in case of an accident that may unexpectedly cause death or dismemberment. In the event of losing an arm or losing your life, the policy should pay benefits to your chosen beneficiaries because of an accident. Another added benefit of these policy types is it doesn’t matter where you pass or get injured.
The payouts from AD&D insurance benefits usually match the face value of the insured’s original life insurance coverage. This means beneficiaries could receive twice the benefit. It’s important to understand, however, that accidental death and dismemberment policies cover incidents outside the norm, and the carriers use this to their advantage when denying rightfully due claims.
At its most base explanation, an AD&D insurance policy accidental deaths and dismemberments. While every insurer has its own list of exceptions as to what qualifies for death benefits under their guidelines, typical circumstances that receive coverage include:
- Weather-related fatalities
- Automotive accidents
- Equipment-related fatalities (construction, medical, etc.)
These situations are not guarantees of claim approval, and many times, the insurance company will take into account the facts leading up to death.
When one loses a body part or the ability to use it, including sight, the ability to speak, or hearing loss, it falls under dismemberment. AD&D policies typically payout in percentages when limbs are lost, or the ability to use them is not possible or reduced.
The level of injuries covered and the types are dependent upon the insurer and the policy you purchased. With that said, it is not very often that coverages will pay the full value of the promised benefit short of actual limb loss or severe bodily function impairment. More importantly, to qualify a claim, it is critical to demonstrate that the policyholder had no part in causing the accident, which later resulted in these types of injuries or death.
In events that may cause the unexpected passing of the insured, but are part of the specific policy exclusions, the likelihood of claim denials is high. This fact highlights how complicated and subject to interpretation AD&D insurance can really be.
Despite AD&D having the word "accidental" in its very name, it hardly means that every deadly accident will get a benefit payout. Insurance companies have many exclusions that help protect them from having to give beneficiaries the compensation they should receive.
One example would be dying of natural causes, like a heart attack. Though it may come unexpectedly, it wasn’t an accident, and the insurance carrier would point this out in their denial. Suicide or injuring oneself as a result of self-harm are other situations that are typically not included in the coverage.
Additional circumstances that AD&D policy providers do not cover are:
- Injuries suffered while committing crimes
- Drunk driving deaths
- Risky sports like skydiving
- Racing cars (professionally or privately)
- Drug overdoses
Sometimes a claim denial has nothing to do with how your loved one passed away or how you lost your limb. There are numerous excuses that life insurance carriers use to avoid paying benefits your family qualifies for, including some of the below scenarios:
- A lapse in the insured’s policy
- Beneficiary murders the insured
- Making false income statements
- Not disclosing information about another life insurance policy
- Giving false information to the carrier or its agent
- Purposely or accidentally failing to share health information
- Lying about high-risk activities you participate in
- Hiding the fact you smoke
- Misrepresenting any information about yourself to the insurance company
While misrepresenting information about oneself on an application to get coverage isn’t uncommon, many life insurance companies don't usually go out of their way to investigate these details when first issuing a policy. The times when application information and other submitted details come under scrutiny is if the covered individual dies or experiences dismemberment in the first two years of the policy being in effect. This time frame is also known as the contestability period and involves a process called post-claim underwriting.
When a loved one passes under conditions that would qualify a claim for AD&D benefits, the insurance company will investigate every aspect of the policy, looking for any possible mistakes or outright falsifications of information by the decedent. If instances of these actions come to light, you can expect the carrier to deny the claim and probably return the paid premiums back to the family. This situation underscores the importance of having an experienced life insurance attorney on hand to represent you and force the carrier to not misconstrue information they see as erroneous.
In many cases, insurers will deny accidental death and dismemberment claims because of a misrepresentation that had nothing to do with how your loved one died or received their injuries. Federal courts have sided with carriers many times on these ground and rendered contracts void from their outset because of facts on the life insurance application were not accurate or purposely falsified.
In addition to this, there are a few other reasons that your claim may receive a denial.
It is a possibility to have your AD&D benefits denied your beneficiaries because the claim filing occurred outside of a determined time frame. It isn’t unusual for these deadlines to be different than those on your regular life insurance policy. Having a lawyer available to help you with an appeal may be one method of overcoming this denial.
Employer-funded accidental death and dismemberment plans fall under the Employee Retirement Insurance Security Act (ERISA). This federal preempt those of your state, which means the appeal process could be radically different and challenging to navigate without an experienced life insurance claims attorney to guide you.
Pre-existing conditions like high blood pressure, obesity, and diabetes are a fact of life for millions of Americans every day. Life insurance companies understand this and still cover individuals with these health problems, but will possibly use them later as an excuse for a denial of benefits. The full extent of how your medical issue contributed to part or all your passing is of critical importance to the carrier should your family take steps to litigate a claim.
When a claim goes under review when death benefits are at stake, words like predominant, substantially contributed to the cause, and pre-existing will be of intense focus to the insurance company. The courts will have to consider the underlying health problems of the decedent when determining if their death was actually an accident.
Dying by exposure has been a long disputed accidental death scenario for decades because of the many factors that lead up to this type of fatality. Courts do analyze these types of claims carefully and have demonstrated how these differ from typical AD&D qualifications since there could be a number of unknowns that may not give a clear picture of what put the deceased in this dangerous position.
Receiving a denial for your accidental death and dismemberment claim is frustrating, but understand that the reasons given are not necessarily set in stone for your case. It’s possible the insurance company responsible for the policy took advantage of vague information on the application and is trying to avoid a payout.
Could your loved one have put misrepresented information on the original application? Is the insurer purposely ignoring important facts surrounding your loved one’s passing? These questions are best addressed by an experienced life insurance attorney who can explain the fine print of your policy and clear up any ambiguous terminology that is manipulating the outcome of your case.
You may be facing a denial of death benefits because the policy carrier has decided that the decedent didn’t die of a qualifying accident but numerous causes that eventually culminated in their passing. Trying to make sense of this reasoning and the legal terminology will make this even more upsetting, and this is the intention of large insurance corporations. They will stoop to many different levels to find ways out of their obligation to give you the payout your family needs.
Don’t put yourself through the emotional and financial hardship of fighting for a death benefits claim on your own. Working with an experienced lawyer can help take this burden off of your shoulders and allow you to focus on picking up the pieces after losing someone dear to you because of an unexpected accident.
Outside of explaining in understandable terms the language of your AD&D policy and what your rights are when pursuing a claim, a legal expert will represent you and put a stop to manipulative insurer tactics to avoid paying benefits.
Knowledgeable attorneys do more than argue your case-- they build it. They research and investigate everything involved with the case, including:
- Coroner reports
- Get and review eyewitness testimony
- Investigate accident reports
- Review toxicology reports
- Check the findings on the death certificate
These law professionals will also have the experience and case history under their belt to compare your situations to others they have successfully represented at any level, from state to federal court. There are even instances where they might need to hire an expert to reconstruct the accident or use a medical professional to explain the circumstances of death. More importantly, your chosen counsel will be well aware of the filing deadline and the amount of evidence you need to appeal and overturn your denied claim.
If you are part of an ERISA case, the complexities of which encourage a sense of false confidence on the part of the insurer that the beneficiaries will give up with an outright AD&D insurance claim denial. These cases require an appeal with significant evidence to back up the demand for payment, and claimants do not get second-chances at submitting these.
If you are in the midst of trying to start an accidental death and dismemberment claim or have already received your first denial, protect your right, and contact a qualified AD&D lawyer immediately. During this difficult time of grief and loss, you may not have the wherewithal to navigate and negotiate with your deceased loved one’s life insurance carrier for the payout you are due.
Contact us today