Our life insurance attorneys recently secured a $425,000 payout for a beneficiary after Protective Life denied the claim based on alleged policy exclusions. The policy included both standard life insurance coverage and an accidental death and dismemberment rider. After a detailed review of the policy language, medical records, and investigative materials, we proved that the exclusions cited by the insurer did not apply. Protective Life reversed its decision and paid the full benefit.
This case highlights one of the most common and most misunderstood causes of life insurance claim denials: exclusions that are applied too broadly or incorrectly. Insurers frequently rely on exclusion language to justify denials, even when the facts do not support that interpretation. Understanding how exclusions work and how they are often misused is critical for beneficiaries facing a denial.
How Policy Exclusions Are Supposed to Work
Policy exclusions are contractual limits that define situations where coverage does not apply. They are not meant to be catch-all provisions. An insurer bears the burden of proving that an exclusion clearly applies to the specific cause of death. If the exclusion is vague, ambiguous, or only loosely connected to the facts, courts generally interpret the policy in favor of coverage.
In the Protective Life case, the insurer attempted to rely on an exclusion related to alcohol involvement. Their position was based on toxicology findings alone, without proof that alcohol caused or contributed to the death. That distinction mattered, and it ultimately decided the case.
Common Exclusions in Standard Life Insurance Policies
Most traditional life insurance policies contain a limited set of exclusions. The most common include:
Suicide Clauses
Nearly all life insurance policies include a suicide exclusion during the first one or two years after the policy takes effect. If the insured dies by suicide during that window, the insurer typically refunds premiums instead of paying the death benefit. After the exclusion period ends, suicide is generally covered.
Contestability and Misrepresentation
During the first two years of the policy, insurers may investigate the application for misstatements. To deny a claim, they must show that the omission or error was material and would have affected underwriting. Minor or unrelated inaccuracies are often improperly used to justify rescission.
Illegal Activity Exclusions
Some policies exclude deaths that occur during the commission of a felony. These exclusions are often misapplied. The insurer must show both that illegal activity occurred and that it directly caused the death.
High Risk Activity Exclusions
Certain policies exclude deaths related to activities such as private aviation, scuba diving, or skydiving unless disclosed or covered by rider. Insurers frequently stretch these exclusions to cover activities that do not fall within the policy definition.
War or Military Service
Some older or specialized policies exclude deaths related to acts of war or active military service. Many modern civilian policies do not include this exclusion, but insurers sometimes rely on outdated interpretations.
How AD&D Exclusions Are Commonly Misused
Accidental death and dismemberment coverage is narrower than standard life insurance, and insurers deny AD&D claims far more aggressively. Common AD&D exclusions include:
Medical or Natural Causes
AD&D policies only cover deaths caused by sudden, external, and accidental events. Insurers often deny claims by reclassifying accidents as medical events, even when trauma clearly caused the death.
Alcohol or Drug Involvement
Many AD&D policies exclude deaths caused by intoxication. The key issue is causation. The presence of alcohol or drugs does not automatically disqualify a claim. The insurer must prove impairment caused the accident.
Illness or Infection
Insurers frequently deny claims by arguing that an illness contributed to the injury or death. Courts often reject these denials when the illness merely made the insured more vulnerable rather than causing the accident.
Self Inflicted Injury
Intentional self harm is excluded. Insurers sometimes misclassify accidental overdoses, falls, or firearm incidents as intentional acts without sufficient evidence.
Why Exclusion Based Denials Are Often Wrong
Exclusion denials fail for several reasons:
The exclusion is vague or undefined
The insurer cannot prove causation
The exclusion conflicts with other policy provisions
The insurer relies on assumptions instead of evidence
The policy language is ambiguous and must be interpreted in favor of coverage
In the $425,000 Protective Life case, the insurer relied on a toxicology report without investigating the accident scene or addressing contradictory medical findings. Once those weaknesses were exposed, the denial collapsed.
What Beneficiaries Should Do After an Exclusion Denial
If a life insurance claim is denied based on exclusions, beneficiaries should not assume the insurer is correct. Practical steps include:
Requesting the complete claim file and denial rationale
Reviewing the policy language carefully
Examining whether the exclusion clearly applies to the cause of death
Consulting a life insurance attorney to assess legal weaknesses
Filing an appeal supported by medical, forensic, or expert evidence
Many exclusion denials are overturned once insurers are forced to defend their interpretation under legal scrutiny.
When Legal Pressure Changes the Outcome
Insurance companies count on beneficiaries accepting exclusion denials without challenge. But as this $425,000 Protective Life recovery shows, exclusions are one of the most vulnerable parts of an insurer’s denial strategy. When applied incorrectly, they often cannot withstand legal review.
If your life insurance claim was denied due to an exclusion, especially one involving alcohol, alleged medical causes, or AD&D coverage, a detailed legal analysis may reveal that the denial is improper.