Our life insurance attorneys recently secured a $90,000 payout for a beneficiary after Guardian Life denied the claim by relying on ambiguous policy language. The insurer pointed to a loosely worded clause that, in their view, excluded coverage based on how the insured’s death occurred. But when we examined the full policy, we found internal contradictions and undefined terms that opened the door for multiple interpretations. Applying longstanding legal principles that require such ambiguities to be interpreted in favor of the policyholder, we successfully forced Guardian Life to reverse its decision and pay the full benefit.
This case is a textbook example of how life insurance companies use vague policy wording to justify denials and how those denials can be overturned with skilled legal advocacy. If you have Pennsylvania life insurance claim issues call us.
When Insurers Deny Claims Based on Ambiguous Language
Life insurance policies are contracts, and like any contract, they must be interpreted according to clear legal rules. One of the most important of those rules is that ambiguities are construed against the drafter—which in the case of insurance policies, is always the insurance company. If a clause can be reasonably interpreted in more than one way, courts typically favor the interpretation that supports coverage.
Despite this, insurers routinely issue policies filled with gray areas, undefined terms, and conflicting clauses. These ambiguities often remain dormant until the insured dies. Then, when the beneficiary files a claim, the company applies the most restrictive interpretation possible and denies payment.
That’s exactly what happened in the Guardian Life case. The policy included an accidental death benefit rider that excluded coverage for deaths caused “directly or indirectly by illness.” When the insured died following a fall that led to a fatal head injury, Guardian Life argued the fall was “indirectly” related to a previously diagnosed neurological condition—even though the official cause of death was trauma. Our team countered that this interpretation was overly broad and inconsistent with how other sections of the policy defined accident-related coverage. The claim was paid in full after we threatened litigation.
Real-World Examples of Ambiguous Language Used to Deny Claims
Our firm has seen dozens of life insurance denials that hinge on vague or misleading policy terms. Here are several common examples where we’ve intervened:
Unclear “Accident” Definitions: One insurer denied a $125,000 claim by asserting that a death from drowning was not accidental because the decedent had consumed alcohol beforehand. The policy didn’t define accident or specify that intoxication voided coverage. We reversed the denial.
Undefined “High-Risk Activity” Exclusions: A $300,000 claim was denied because the insured died in a motorcycle crash. The policy excluded “high-risk activity,” but failed to define the term. Our attorneys argued that ambiguity made the clause unenforceable. The claim was paid after appeal.
Vague Suicide Exclusion Timing: A client’s $50,000 claim was denied under a suicide exclusion that mentioned a “two-year period” but did not specify whether that period started at application or issuance. We established that the exclusion had expired before the death. Full payment followed.
Ambiguous Health Questions on Application: In another case, a $100,000 claim was denied due to alleged misrepresentation. The application had asked if the applicant had been “treated for any disorder,” without defining treatment or timeframe. Our legal team demonstrated that the question was too vague to support a fraud accusation, and the denial was rescinded.
Contradictory Coverage Clauses: A $250,000 group policy provided coverage for death while traveling but excluded deaths related to “foreign travel risks.” When the insured died abroad, the insurer cited this exclusion. We proved the policy language was self-contradictory, and the claim was paid.
These denials reflect a broader pattern: insurers drafting policies with just enough flexibility to deny claims after the fact. The policyholder believes they are protected, only for the beneficiary to discover that critical terms were either unclear or misleading.
Courts Favor Policyholders When Language Is Vague
In contract law, and especially in insurance litigation, the legal doctrine of contra proferentem plays a central role. This principle requires that when a contract term is ambiguous, the court must adopt the interpretation that favors the non-drafting party in this case, the insured or beneficiary. This is not just theory. Courts across the country have applied this doctrine to award millions in benefits that were initially denied due to policy ambiguity.
In the Guardian Life matter, we relied on this exact doctrine, along with case law from prior denials involving accidental death riders. We showed that Guardian Life’s interpretation was both legally and factually unsupportable, and we highlighted prior decisions where similar language had been deemed too vague to enforce. The result was a full reversal and recovery of the $90,000 death benefit.
Legal Representation Is Critical When Facing an Ambiguous Denial
Most people do not have the background to analyze a life insurance contract’s legal nuances especially when grieving the loss of a loved one. Insurers take advantage of this knowledge gap and often present denials as final, citing internal interpretations that sound authoritative but are legally weak.
Our firm challenges those denials. We dissect the policy language, identify contradictions, demand production of underwriting materials, and present the strongest possible legal position to force payment. If your claim has been denied because of vague or unclear language, we can help.