Our law firm recently secured a $525,000 payout in a denied accidental death and dismemberment (AD&D) case. The insurance company initially rejected the claim, arguing that the death was excluded under the policy’s fine print. After carefully reviewing the contract and launching a legal appeal, we proved the exclusion did not apply. The full benefit was recovered for our client’s family.
This case is far from unique. Many AD&D claims are denied based on policy loopholes or ambiguous terms. Our experience shows these denials can often be overturned especially when they’re based on biased or overly narrow interpretations. If you need help with denied life insurance in New Mexico call us.
What Is Accidental Death and Dismemberment Insurance?
AD&D insurance pays a financial benefit if an insured person dies or suffers a severe injury due to a covered accident. It’s often added to traditional life insurance or offered as workplace coverage. However, the definition of "accident" is not always as straightforward as it seems. Insurers routinely deny AD&D claims, arguing that the injury wasn’t truly accidental, that an exclusion applies, or that a deadline or technical requirement wasn’t met.
To better understand these tactics, here are 30 specific reasons AD&D claims are denied—each one with an example pulled from real-world cases.
30 Reasons Why AD&D Claims Are Denied (With Examples)
1. Injury or death not deemed accidental
An insured collapsed while walking and hit their head. The insurer claimed the fall was due to a stroke a natural cause not an accident.
2. Policy not active at the time
A man switched jobs and lost his workplace AD&D coverage. Two months later, he died in a car accident, but the old policy had already ended.
3. Incident excluded under policy terms
The insured died during a recreational dive. The policy specifically excluded scuba-related deaths, leading to denial.
4. Lapsed policy due to missed premiums
An individual missed two payments during a financial crisis. After a fatal bike crash, the insurer pointed to policy lapse.
5. Pre-existing condition contributed
A woman died in a fall, but records showed she had severe vertigo. The insurer argued the condition caused the fall and denied the claim.
6. Self-inflicted injury or suicide
A man died from a gunshot wound. The insurer classified the incident as intentional and denied the AD&D benefit under the suicide exclusion.
7. Intoxication at time of death
Toxicology showed the insured had a high blood alcohol content. Though the accident was otherwise covered, the insurer applied an intoxication exclusion.
8. Criminal activity at time of event
The insured died in a motorcycle crash while fleeing a theft scene. The claim was denied due to involvement in criminal activity.
9. Extreme sport or high-risk activity
A death occurred during a skydiving event. The insurer cited the exclusion for “hazardous activities” and denied the payout.
10. War zone or active military conflict
A contractor was killed in a drone strike while working overseas. The insurer invoked the war exclusion clause.
11. Felonious behavior contributed
An individual died during an attempted armed robbery. Since a felony was underway, the policy was rendered void.
12. Riot or civil disturbance
The insured was fatally injured during a violent protest. The insurer rejected the claim due to a civil unrest exclusion.
13. Act of terrorism excluded
A tourist died during a hotel bombing abroad. The policy excluded terrorism-related events, and the insurer refused payment.
14. Death determined to be natural cause
A man was found dead at the bottom of stairs. Autopsy showed a heart attack caused the fall, so the insurer deemed it a natural death.
15. Lack of evidence supporting accidental cause
No eyewitnesses or camera footage could confirm the insured slipped on ice. The insurer said the accident could not be verified.
16. Death outside policy’s coverage area
An insured person died during a mission trip in a country excluded by the policy. The claim was denied due to geographic limitations.
17. Claim filed after coverage ended
An employee died in an accident after their job ended and group coverage expired. The claim was submitted too late to qualify.
18. No insurable interest existed
A distant acquaintance purchased a policy without financial dependence. When the insured died, the insurer found no insurable interest and denied the claim.
19. Unauthorized policy purchase
An ex-business partner obtained AD&D coverage on someone without consent. The claim was voided for lack of authorization.
20. Beneficiary not named in policy
The family filed a claim, but the policy only listed “estate.” Without formal designation or probate documents, the insurer delayed and then denied the claim.
21. Beneficiary lacked insurable interest
A policy listed a friend as beneficiary. The insurer questioned the relationship and denied the claim under local laws requiring financial connection.
22. Named beneficiary had passed away
The beneficiary died before the insured. No contingent was listed, so the insurer denied the payout rather than defaulting to next-of-kin.
23. Minor beneficiary with no guardian
A child was the named beneficiary. No trustee or legal guardian had been assigned, which led to significant delay and eventual denial.
24. Beneficiary was not a legal resident
A claim filed from abroad was denied after the insurer said the foreign resident beneficiary did not meet eligibility requirements.
25. Beneficiary had no family relationship
An unrelated caregiver was named as the beneficiary. The insurer argued it was an improper designation and rejected the claim.
26. Name recorded incorrectly on forms
A misspelled name caused identity confusion. The insurer refused to process the claim until corrected, then denied it based on filing deadlines.
27. Claims procedure not followed
A family submitted hospital records but missed the insurer’s accident report requirement. The incomplete file triggered denial.
28. Late notice of the accident
The insurer required notification within 60 days. The beneficiary waited four months, and the claim was denied as untimely.
29. Policy waiting period had not elapsed
The insured died in an accident one week after the policy began. The policy had a 30-day waiting period, and the claim was denied.
30. Insurer applied overly strict definitions
A man fell down icy stairs and suffered a brain injury. The insurer claimed the fall was “not a direct cause” of the coma and denied the benefit.
Challenging a Denied AD&D Claim Is Possible
Insurance companies frequently deny AD&D claims using narrow policy language or debatable interpretations of the facts. But as our recent $525,000 recovery shows, those denials are not always final. Many claims are wrongfully rejected based on assumptions, hidden clauses, or misapplied exclusions.
If your accidental death or dismemberment claim has been denied, do not assume the insurer’s decision is correct. Our attorneys specialize in fighting these denials and recovering the compensation families deserve. Contact us today for a free evaluation. We only get paid if you recover.