Our life insurance dispute law firm has seen insurers deny AD&D benefits based on technicalities and unfair interpretations of policy language. If your AD&D claim has been denied, our top attorneys will fight to recover the full benefits owed.
Top 20 Reasons AD&D Insurance Claims Are Denied
The death did not result from an accident – AD&D policies only cover accidental injuries or deaths. If the insurer determines the death was due to illness, natural causes, or other non-accidental events, they will deny the claim.
Injuries were not severe enough to qualify – Dismemberment benefits require a specific level of severity. Minor or partial injuries may not meet the threshold defined in the policy.
A pre-existing condition contributed to the injury or death – If the insurer believes a medical condition played a role, they may argue the outcome was not strictly due to an accident.
Risky behavior or illegal activity at the time of the accident – Injuries sustained while committing a crime, fleeing police, or engaging in reckless behavior can lead to denial.
The insured was not covered at the time of the incident – If the policy had lapsed or coverage had not yet started, the claim will be denied for lack of coverage.
Failure to disclose medical history on the application – Misstatements or omissions regarding health can lead to rescission of the policy and denial of benefits.
Alcohol or drug use at the time of the accident – Many policies exclude coverage if the insured was intoxicated or under the influence when the accident occurred.
Self-inflicted injuries or intentional harm – AD&D policies do not cover suicide, self-harm, or injuries caused by intentional actions.
Delayed medical treatment – If the insured failed to seek prompt medical attention, insurers may claim the injuries were not directly related to the accident or worsened by delay.
Excluded causes such as war or natural disaster – Policies often exclude deaths related to war, natural catastrophes, or civil unrest.
Participation in a hazardous activity – Activities like rock climbing, skydiving, or motor racing may be specifically excluded from coverage.
Mental or emotional disorder contributing to the incident – If the insurer believes a psychological condition played a role, the claim may be denied based on mental illness exclusions.
Death during criminal activity or riot participation – If the insured died during illegal activity or civil disturbance, the insurer may apply criminal exclusions.
Injury or death resulting from medical treatment – AD&D does not typically cover injuries caused by medical malpractice, surgery, or diagnostic procedures.
Military service exclusion – Some policies exclude coverage for individuals who die or are injured while serving in the military or during training exercises.
Failure to wear safety gear (e.g., seatbelt) – If the insured was not wearing a seatbelt or helmet as required, the insurer may argue contributory negligence and deny the claim.
Sports-related exclusions – Injuries during professional or high-risk sports may fall outside the scope of coverage, particularly in policies with specific exclusions.
Terrorism-related injuries or deaths – Some policies exclude events linked to terrorism, particularly if they occur during travel abroad or in conflict zones.
Exposure to toxic substances – Death or injury from chemicals or toxins may be denied if the policy excludes exposure-related causes.
Death or injury resulting from the insured’s criminal act – If the insured committed a felony or violent crime leading to their own injury or death, the policy may not pay.
Understanding the fine print in an AD&D policy is critical. Insurers often rely on vague or overly broad exclusion clauses to withhold payouts. If your claim has been denied, we can help you challenge the decision and win.
FAQ: Denied Accidental Death and Dismemberment (AD&D) Insurance Claims
What is an accidental death and dismemberment (AD&D) policy?
AD&D insurance provides a payout if the insured dies or suffers specific serious injuries due to a qualifying accident. It is often added as a rider to life insurance or offered as standalone coverage.
Are all accidental deaths covered under AD&D policies?
No. Coverage is subject to strict definitions of "accident" and often excludes deaths resulting from illness, self-harm, substance use, or criminal activity.
Can drug or alcohol use void AD&D coverage?
Yes. If the insured was under the influence of drugs or alcohol at the time of the accident, the insurer may deny the claim based on intoxication exclusions.
What is a dismemberment benefit?
It is a partial payout provided for the loss of limbs, eyesight, hearing, or other major physical functions as a result of an accident. Each policy specifies what qualifies.
Is suicide covered under AD&D?
No. Deaths due to suicide or self-inflicted injuries are almost always excluded under AD&D policies.
Can a claim be denied if the accident was caused by a pre-existing condition?
Yes. If the insurer argues that a health condition contributed to the accident or death, they may deny coverage on that basis.
Do AD&D policies cover injuries from sports or extreme activities?
Not always. Many policies exclude high-risk or professional sports. It’s important to check the exclusions in your specific plan.
What happens if the insured wasn’t wearing a seatbelt?
If the policy requires the use of safety gear and the insured failed to comply, the claim may be denied due to contributory negligence.
Is coverage denied if the insured died while committing a crime?
Yes. Most policies exclude coverage for injuries or death occurring during criminal acts.
Are injuries from medical procedures covered?
Generally, no. AD&D policies usually exclude injuries resulting from medical treatment, surgery, or medication.
Can mental illness affect an AD&D claim?
Yes. If the insurer believes the incident was influenced by a mental or emotional condition, they may deny the claim under mental health exclusions.
What if the insurer claims the event wasn’t truly accidental?
That is a common denial tactic. Our attorneys can challenge these determinations using medical and legal evidence to prove the event qualifies as an accident.
Can an AD&D policy be rescinded after death?
Yes, particularly if the insurer believes the application included false or omitted information. This can result in claim denial and policy cancellation.
Do group AD&D policies offered through employers have different rules?
Yes. Group AD&D coverage may fall under ERISA and involve different claims and appeal procedures. Deadlines are also stricter.
Is there an appeal process if my AD&D claim is denied?
Yes. You can appeal a denial directly with the insurer, and if necessary, file a lawsuit. Legal guidance is essential to succeed in this process.
Do I need an attorney if my AD&D claim is denied?
Absolutely. Insurers often rely on technicalities or exclusions to avoid paying valid claims. An experienced life insurance attorney can fight back and recover what you’re owed.