Denied AD&D Claim Lawyer
It is very common for people to buy accidental death and dismemberment (AD&D) coverage along with regular life insurance. AD&D coverage is available as a separate policy or as a rider to a life insurance policy. As a separate contract, an accidental death policy pays a benefit in the event that the insured dies in an accident or due to accidental means or loses one or more limbs, hearing or vision. An AD&D policy is usually less expensive than regular life insurance coverage that pays benefits for almost all types of death
A rider to a complete life insurance policy is a separate section of a life insurance contract. It pays a sum of money to the beneficiary if the insured dies as a result of an accident or due to accidental means. An AD&D rider is often called double indemnity and pays double or even triple the amount of a regular life insurance payout. It is common for such a rider to also provide benefits for dismemberment, when the insured is alive but loses a limb, vision or hearing. A rider attached to a life insurance contract will raise a premium slightly.
Many people buying AD&D coverage do not suspect that an insurance company may deny an AD&D claim even if the death was accidental. Beneficiaries whose AD&D claims have been denied may feel confused, frustrated and cheated by insurance companies whose contracts are worded in such a way as to allow multiple interpretations. The reason why insurers routinely deny seemingly valid AD&D claim is because every policy or rider has multiple exclusions. Thus, for example, many AD&D policies do not pay benefits if the insured died in an accident, but was intoxicated over the state legal limit. Another common exclusion is an accidental death that was contributed to by the insured's illness or treatment thereof. The problem with this exclusion is that, technically, it can apply to every individual, since it is very rare that a person does not have a single illness. What insurance companies do wrongfully is that they deny valid claims by stating that the sickness of the insured had somehow contributed to the death and, therefore, the sickness exclusion applies canceling liability on the claim.
Before we appeal an AD&D claim denial, we conduct a careful investigation of the complete file of the insured - the policy, medical records, toxicology reports, medical examiner's reports, coroner's reports, death certificate, etc. – to determine the true cause of the death and whether the policy terms have been properly interpreted by the insurance company. We also conduct extensive legal research to determine how factually similar cases were resolved in U.S. state and federal courts. If necessary, we hire medical experts to prepare expert opinions as to the true cause of the insured's death. In motor vehicle accident cases, we may hire an accident scene reconstructionist who will help the court see how the accident occurred. This is especially useful in cases where the insured died in a car accident that was caused by a tire blowout or another mechanical defect, but the insurance company claims that the insured was either intoxicated or suffered from a medical condition that resulted in his loss of control of the vehicle.
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 your AD&D claim was denied based on the application of a sickness exclusion, call our life insurance attorneys for help. We have experience working with life insurance claim denials and will provide the high legal representation you expect.
Caution: Make sure your AD&D lawyer has a minimum of 15 years experience. We fired a couple young lawyers, and they are trying to resolve these cases themselves, and their clients end up retaining us after they are unsuccessful.
You can learn about denied life insurance ERISA claims next.