Our law firm specializes in the wrongful denial of life insurance claims. We have done this work for years and consequently, we know the industry well. For example, we know that life insurance companies hate paying out lots of money to beneficiaries. Every time they are forced to make a large payout, they have smaller profits to show their shareholders at the end of each fiscal year. That’s not good business for them.
In light of this, it is not surprising that life insurance companies are extremely hesitant to pay accidental death and dismemberment (“AD&D”) claims. In essence, if a life insurance policy has an AD&D rider, the insurance company may have to pay out a lot more money when one of its insured’s passes away. Typically, an AD&D rider states that if the policyholder dies as the result of an accident, the insurer must pay the regular policy amount, plus an additional three times that amount. So if a person had a $100,000 life insurance policy with an AD&D rider and they pass away in an accident, the insurance company would be forced to pay the beneficiary $100,000, plus an additional $300,000 for the AD&D rider.
Not surprisingly, we frequently see life insurance claims adjusters trying to make the case that an accidental death wasn’t accidental at all. Even in the most obvious accident cases, we’ll see them argue that a death was the result of natural causes or some purposeful act. Sometimes, in fact, their efforts border on the ludicrous. Nonetheless, they continue to make these denials because they know most beneficiaries without specialized counsel will simply accept their bogus decisions. This article presents one such case.
A freak holiday accident
The case involved a man named Rafael. Rafael was married to a woman named Cindy and the couple had three children. Rafael was a successful mechanical engineer with a high-paying job that offered great benefits. Among those benefits was a $400,000 life insurance policy with an AD&D rider that would pay an additional $1.2 million if Rafael died in an accident. Rafael named Cindy as his sole beneficiary under this policy.
One Thanksgiving, Rafael took Cindy and the three kids to his parents’ house. All of his siblings and cousins would be there, along with all of the children and grandchildren. One of the family traditions was a football game that was held in Rafael’s parents’ large front yard following the midday meal.
On this particular day, Rafael was playing wide receiver. His cousin Jimmy, the quarterback, called for a play that required Rafael to catch the ball on the run in the middle of the field. The play started off as planned. Rafael caught the ball midfield and proceeded to head toward the end zone. As he made the turn, however, he ran head-first into another cousin. In fact, the two men’s heads collided at full speed. Rafael dropped instantly onto the grass. Within 30 minutes, he was dead from what doctors would later describe as a major brain contusion.
The whole family was obviously devastated by this accident. It gave them a little comfort to know that at least Rafael was well-insured and that Cindy and the kids would be taken care of by virtue of his life insurance policy. Cindy explained to them that Rafael had paid extra for the AD&D rider and that it would provide them with a much greater benefit than just a standard policy.
An unfair denial
Imagine the family’s surprise when Cindy received a letter in the mail denying the AD&D portion of her claim against Rafael’s policy. According to the insurance company, Rafael had chosen to participate in a highly dangerous sport (football) and had chosen to play the game without a helmet. This “reckless” behavior, according to the insurance company, rendered Rafael’s death as more “purposeful” than “accidental.” Accordingly, it was denying that portion of the claim that would have paid $1.2 million for an accidental death.
The denial letter shocked everyone in the family. Luckily, one of the cousins was an attorney. He referred Cindy to a colleague who specialized in the wrongful denial of life insurance claims. That attorney immediately identified the problem – the insurance company was throwing out a bogus narrative about a “purposeful” death in an effort to save itself over a million dollars. The insurer knew that the vast majority of beneficiaries never contest the denial of an AD&D claim, especially if the insurance company paid out something on the underlying life insurance claim.
After reviewing all the police and hospital reports surrounding Rafael’s death, the attorney put together a strongly-worded letter and packet of evidence for the insurance company’s internal appeals board. In the letter, the attorney noted that all official reports concerning Rafael’s death deemed his death an accident. Moreover, the attorney was able to cite to numerous other cases where deaths relating from sports injuries were deemed an “accident” for purposes of insurance.
After several phone calls, the appeals board agreed with the attorney that a denial of the AD&D claim denial was warranted. The truth was, that appeals board had fought that same attorney in court several times and had lost each time. Ultimately, it was cheaper for the insurer to simply pay the claim than to fight a losing battle in court.
This case is a perfect illustration of why it is so important to retain a specialized attorney when dealing with the denial of an AD&D claim. These attorneys fight phony claim denials all the time. They know the attorneys who work for the insurance companies from fighting them on so many claims. Over time, they build up a level of respect. Consequently, they’re in a much better position to negotiate a fair resolution.
Our firm is laser-focused on contesting the wrongful denial of life insurance claims (including AD&D claims). If you have received a claim denial letter that just doesn’t make sense to you, call us. We’re here to help.