Accidental death and dismemberment insurance, often called AD&D, pays benefits when a person dies or is seriously injured as a result of a sudden and unexpected accident. Unlike standard life insurance, these policies do not cover illness or natural causes. To qualify for payment, the death must be directly caused by an accident and fall within the terms of the policy.
One common dispute arises when a person dies during a recreational activity like scuba diving or skydiving. If the insurer finds any evidence of a medical condition, such as a heart issue that occurred moments before the accident, they may deny the claim by arguing that the death was due to illness rather than impact. These cases are often challenged and depend heavily on the medical examiner’s report and policy language. If you need life insurance claim help in New Jersey call us.
Accidental Deaths That Are Usually Covered
AD&D policies typically cover deaths caused by physical accidents. Car crashes are among the most frequently approved claims. A delivery driver who was struck by a distracted motorist while on the job left behind a policy that paid out without delay. The police report and autopsy confirmed that the death was accidental and not caused by a health issue.
Fires are also covered when the death results from burns, smoke inhalation, or falling debris. In one case, a tenant died of asphyxiation in an apartment fire. Despite having asthma, the insurer accepted the claim because the fire was a sudden external event and the preexisting condition was not the cause of death.
Drowning incidents often qualify when the person had no history of seizures or substance use. A camper who drowned during a supervised swim met the criteria, and the family received the full benefit after the toxicology report came back clean.
Fatal falls are another area where claims are usually approved. A man slipped on a wet hotel stairwell, hit his head, and died within hours. Surveillance footage showed the fall, and there was no indication of a stroke or medical event. The insurer initially delayed the claim but paid after receiving supporting documentation from the hospital.
Accidental poisoning and industrial incidents such as explosions or machinery malfunctions are also recognized causes. A worker who inhaled chemical fumes during a factory mishap died two days later. The claim was processed successfully because the exposure was considered both unintentional and job related.
Many policies require that the death occur within one year of the accident. If someone suffers complications months later, the insurer may argue that the accident was not the primary cause of death. This is often where legal disputes begin.
What Is Usually Excluded from AD&D Policies
Insurers outline several exclusions in these policies, and many are used as the basis for denial.
Deaths involving intentional self harm are excluded, even if the act was impulsive or related to mental illness. A teenager who participated in an internet challenge that involved oxygen deprivation died during the act. Although the family believed it was accidental, the insurer denied the claim by categorizing the behavior as deliberate.
If the insured was engaged in criminal activity at the time of death, that may also bar coverage. A young man who was trespassing on railroad property was struck by a train. Even though his death was not planned or expected, the insurer denied the claim because he was on private property without permission.
Alcohol or drug use frequently triggers a denial. One construction worker fell from scaffolding and died. Toxicology showed mild alcohol in his system. The insurer argued he was impaired and refused to pay. His family challenged the decision and submitted statements from coworkers who said he showed no signs of impairment. The case eventually settled.
Deaths caused during medical treatment are excluded as well. If someone dies due to a reaction during surgery or a mistake during recovery, the insurer will typically deny the claim because the event took place in a controlled setting and involved medical care rather than an external accident.
Other common exclusions include deaths during active military service, deaths linked to professional racing or extreme sports, and fatalities caused by autoerotic practices. Even when the cause of death looks accidental, the surrounding context matters greatly.
What to Do If an AD&D Claim Is Denied
If your accidental death claim is denied, the first step is to examine the denial letter. Look for the exact clause the insurer is relying on and ask whether the facts actually support their reasoning. Many policies contain vague language that can be interpreted more than one way.
Then review the full policy, not just the summary. Sometimes the exclusions are buried in small print or only apply in narrow circumstances. Do not assume that the insurer's interpretation is the only valid one.
If the policyholder’s death was clearly caused by an accident and occurred within the required timeframe, you may have a strong case to appeal. Families often win these disputes with the help of a life insurance attorney who can gather medical records, witness statements, autopsy reports, and legal precedent.
In one case, a man died during an amateur skydiving trip. The insurer denied the claim under a clause excluding dangerous recreational activities. However, the policy did not define what qualified as dangerous. After legal review, the court found that the exclusion was too vague to enforce, and the claim was paid.
Final Thoughts
Accidental death insurance can provide crucial financial support after a tragedy, but the claims process is often more difficult than expected. Insurers may deny payment based on technicalities, exclusions, or unclear medical findings. Even legitimate claims can be delayed or disputed if the death is not immediately linked to a clear external cause.
If your claim was denied, do not assume the insurer is right. Review the policy, examine the facts, and speak with an attorney if something feels wrong. These policies exist to protect families after accidents—not to give insurers an excuse to withhold payment.
We handle denied AD&D claims nationwide and are prepared to fight for families who have been unfairly denied the benefits they deserve.