Our law firm has handled thousands of denied ERISA life insurance claims. We’ve recovered benefits from MetLife, Prudential, Lincoln Financial, Unum, Hartford, and others by exposing flaws in their denial justifications. Below are 20 of the most common reasons ERISA claims are denied, each with real-world insights that show how they play out. If you have Alabama life insurance claim issues call us.
Top 20 Reasons ERISA Life Insurance Claims Are Denied
1. Premiums stopped without the insured knowing
A teacher in Minnesota took unpaid leave for medical reasons. Her employer stopped payroll deductions, and the insurer canceled the policy without notice. When she passed away four months later, her claim was denied for nonpayment. We proved that she was never informed of the lapse and secured the full benefit for her family.
2. Misrepresentation during enrollment
Insurers frequently review applications after a death, especially during the first two years. In one case, an administrative worker failed to list her blood pressure medication on the form. She died of a stroke 18 months later. The insurer denied the claim. We demonstrated the omission was not intentional and the policy would have been issued anyway. The claim was paid after appeal.
3. Pre-existing condition not disclosed
ERISA insurers often deny claims based on missing medical history, even if unrelated to the death. One client’s husband failed to mention a prior cancer diagnosis but died of a heart attack. The insurer tried to void the policy. We forced them to acknowledge the two were unrelated and recovered the full payout.
4. Death outside the coverage period
Job transitions create dangerous coverage gaps. A New Jersey father died during the week between jobs. He had elected new group coverage, but it had not yet taken effect. We successfully argued that his prior employer failed to inform him of conversion options, forcing a settlement.
5. Suicide within the exclusion window
Most ERISA policies exclude suicide within the first two years. We handled a case involving a federal employee who died by suicide 19 months after starting coverage. The insurer denied the claim. After obtaining mental health records and timeline discrepancies, we secured a partial settlement.
6. High-risk activity exclusions
An engineer died in a recreational scuba diving accident. His employer-provided policy excluded deaths during underwater activities. His wife had no idea such an exclusion existed. We challenged the exclusion’s application and resolved the claim after months of negotiation.
7. War zone or terrorism-related deaths
We represented the family of a government contractor who died in Iraq during a logistics mission. The insurer cited a terrorism exclusion. We established that he was not in an active combat zone and recovered the full benefit through federal litigation.
8. Drug or alcohol-related death
A Texas man died in a fall at home. His toxicology report showed alcohol use. The insurer denied the claim. We brought in a toxicologist to explain the level of alcohol could not have caused the fall. The denial was reversed.
9. Criminal activity exclusions
Even minor legal issues can trigger denials. One client’s brother died in a motorcycle crash while driving without a valid license. The insurer labeled it “criminal activity.” We demonstrated this was a civil infraction and forced payment.
10. Felony exclusions
A man died during an attempted burglary, and the insurer denied the claim under a felony exclusion. We represented his minor child and showed she had an independent right to the benefit. A court awarded her the payout despite the exclusion.
11. Incomplete or unclear cause of death
When death certificates list “unknown” or “undetermined,” insurers often stall or deny. In one ERISA claim, the insurer delayed for eight months, citing unclear cause. We obtained coroner records, medical testimony, and forced a resolution.
12. Missed filing deadlines
ERISA requires strict adherence to filing timelines. One family waited five months after the funeral to file the claim. The insurer rejected it as untimely. We showed the delay was due to misinformation from the employer and compelled the plan to accept the filing.
13. Policy not in force due to admin error
We’ve handled numerous cases where employers failed to process elections or deductions. In one, a benefits manager never submitted the enrollment form. We proved the employee reasonably believed coverage was in place, and the claim was paid after we filed a federal complaint.
14. Missing or disputed beneficiary forms
A federal employee had no beneficiary form on file. His longtime partner and estranged adult son both made claims. The insurer filed an interpleader lawsuit. We represented the partner and won based on a pattern of financial dependency and supporting documents.
15. Policy lapse from employer negligence
A Virginia nurse continued working after a merger, but her coverage was dropped due to administrative oversight. When she died, the insurer denied the claim. We proved her employer had breached its ERISA duties, and the insurer settled.
16. Fraudulent or forged applications
Dependent policies are sometimes obtained without consent. We handled a case where a spouse was added to a policy without her signature. After she died, the insurer denied the claim. We proved the employer had altered documents internally. The claim was reinstated.
17. Contestability period scrutiny
Even minor issues trigger denials if the death occurs within two years. A policyholder forgot to mention occasional smoking. He died in a car accident, unrelated to tobacco. The insurer denied the claim. We forced them to admit the omission was immaterial.
18. Termination before conversion
Group policies end when employment does, unless the insured converts to an individual plan. One man was laid off and died 10 days later. He was never informed of his conversion rights. We sued the employer for ERISA notice violations and recovered damages.
19. No insurable interest or unauthorized coverage
A woman submitted a claim for her ex-husband’s policy. He had never named her as a beneficiary and had remarried. The claim was denied, and the rightful beneficiary sued. We represented the current spouse and uncovered a forged beneficiary form.
20. Improper policy assignment
One client’s father assigned the policy to a trust, but the paperwork was never completed. After his death, the insurer denied the claim citing improper assignment. We worked with the trustee to validate the intent and secured a favorable settlement.