Fighting Life Insurance Denials Due to Sickness Exclusions
Life insurance policies may contain sickness exclusions that prevent beneficiaries from receiving a death benefit if the insured person passes away due to certain medical conditions. These exclusions are intended to protect insurers from high-risk conditions but can often lead to claim denials in cases where the illness is not clearly covered. If you’ve experienced a denied life insurance claim due to a sickness exclusion, it's essential to understand the common reasons for such denials and how to challenge them.
Common Sickness Exclusions in Life Insurance Policies
Below are some of the most frequently cited sickness exclusions in life insurance claims:
Cancer
If the insured person’s death is directly caused by a cancer diagnosis that occurred before the policy’s effective date, the insurer may deny the claim. Cancer diagnoses made prior to policy issuance can sometimes be considered a pre-existing condition and excluded from coverage.AIDS/HIV
Death resulting from complications related to AIDS or HIV may be excluded due to the pre-existing nature of the condition. Many policies exclude coverage for AIDS-related deaths if the insured person was diagnosed with HIV before purchasing the policy.Alzheimer's Disease
The progressive and chronic nature of Alzheimer’s disease may lead to a denial of claims related to death from this condition. Insurance companies often exclude coverage for conditions like Alzheimer's, which are long-term and not classified as "accidents."Parkinson's Disease
Like Alzheimer’s, Parkinson’s disease is chronic and degenerative. Death from Parkinson’s disease could be excluded if the policy doesn’t cover conditions that progress over time without being classified as an accident.Multiple Sclerosis
If the insured person dies from complications related to multiple sclerosis, which is a progressive and chronic condition, the claim may be denied due to exclusion clauses specific to chronic illnesses.Kidney Failure
End-stage renal failure may be excluded if the policy specifically omits coverage for renal diseases or conditions related to kidney function, especially if it was a pre-existing condition.Chronic Obstructive Pulmonary Disease (COPD)
COPD-related deaths may be denied due to exclusions for respiratory illnesses, especially if the condition developed over time due to smoking or other non-covered lifestyle factors.Liver Cirrhosis
Death resulting from liver cirrhosis may be excluded if the policy excludes liver-related conditions, particularly those that develop due to alcohol use or pre-existing liver disease.Heart Disease
If the insured dies from a heart-related condition, such as coronary artery disease, the claim may be denied if the policy excludes heart diseases or if the condition was diagnosed before the policy was issued.Stroke
Death due to stroke may be excluded in some policies if the policy specifically excludes stroke-related deaths, particularly if the insured person had previous strokes or health conditions that contributed to the stroke.Diabetes
Diabetes-related deaths may be excluded if the policy does not cover complications from diabetes, which can include heart disease, kidney failure, and other complications.Respiratory Failure
Respiratory failure may be excluded if it results from a non-accidental cause, such as chronic respiratory conditions like asthma or COPD.Renal Failure
Renal failure deaths unrelated to kidney disease may be excluded, depending on how the policy defines the causes of death covered under the sickness exclusion.Sepsis and Pneumonia
Deaths caused by infections like sepsis or pneumonia may be excluded under policies that do not cover infectious diseases or those that fall under a "natural cause" exclusion.Mental Illness or Suicide
Many life insurance policies have exclusions for death related to mental illness or suicide, especially within the first two years of the policy, known as the contestability period.Genetic Disorders
Death resulting from complications of genetic disorders like Huntington's disease or cystic fibrosis may be excluded if the policy does not cover hereditary or genetic conditions.Autoimmune Diseases
If the insured dies from complications due to autoimmune diseases, such as lupus or rheumatoid arthritis, the policy may exclude these causes, especially if they were pre-existing conditions.Dementia
Death caused by dementia or its complications may be excluded from coverage under policies that exclude degenerative brain diseases.Amyotrophic Lateral Sclerosis (ALS)
ALS, a progressive and fatal neurological disease, may be excluded due to its chronic nature, and policies may have exclusions related to such conditions.Chronic Heart Failure
Death from chronic heart failure may be excluded if the policy specifically limits coverage for heart failure-related deaths or conditions that are long-term and non-accidental.Organ Failure
Death from organ failure that is unrelated to an injury or covered illness may be excluded, particularly if the organ failure is linked to a non-accidental cause, like cirrhosis or kidney disease.Systemic Lupus Erythematosus (SLE)
Death caused by complications of SLE, an autoimmune disorder, may be excluded if the policy excludes autoimmune diseases or similar conditions.Congenital Disorders
Conditions arising from congenital disorders may be excluded, especially if the policy has an exclusion for pre-existing conditions or birth defects.
Disputed Interpretation of Sickness Exclusions
In some cases, insurance companies misinterpret the sickness exclusions or fail to apply them correctly. Common disputes that lead to denied claims include:
Misapplication of Exclusion
The insurer may misapply the sickness exclusion, arguing that a condition that should be covered falls under an excluded category.Disputed Diagnosis
The insurer may question the diagnosis provided by the attending physician, asserting that the illness does not meet the criteria specified in the sickness exclusion.Ambiguous Language
If the policy’s sickness exclusion is vague or unclear, different interpretations may arise. The insurer may interpret it in a way that denies the claim, while the policyholder argues that the exclusion should not apply to their situation.Coverage Limitation Dispute
Insurers may deny claims for illnesses in early stages, claiming they fall under an exclusion that only applies to severe conditions, even though the insured may not meet the policy's definition of a "critical" illness.Contradictory Policy Language
If the policy contains contradictory clauses, the insurer might apply the sickness exclusion incorrectly. The policyholder can argue that the language should be interpreted in their favor.
How Our Life Insurance Lawyers Can Help
If your life insurance claim was denied due to a sickness exclusion, our experienced attorneys can help you fight the denial and secure the benefits you deserve. We specialize in challenging misinterpretations of policy exclusions and ensuring that insurance companies uphold their obligations to policyholders. Here's how we can assist you:
Reviewing the Policy: We will carefully review the policy language to identify any misapplications of the sickness exclusion or contradictions that could affect your claim.
Gathering Medical Evidence: Our team will help gather the necessary medical evidence to support your claim and challenge the insurer’s reasoning for denial.
Negotiating with Insurers: We will negotiate directly with the insurer to reach a fair resolution or settlement on your behalf.
Pursuing Legal Action: If necessary, we will pursue legal action to ensure that you receive the compensation you are entitled to.
Insurance Companies We’ve Helped with Sickness Exclusion Denials
Our life insurance lawyers have successfully resolved claims with insurers such as:
MetLife
Prudential
AIG
Northwestern Mutual
Nationwide
FAQ Section
Can my life insurance claim be denied because of a sickness exclusion?
Yes, if the illness is explicitly excluded under the terms of the policy, the insurer may deny the claim. However, you can challenge the exclusion if the illness was misinterpreted or if the exclusion was wrongly applied.What should I do if my life insurance claim is denied due to a sickness exclusion?
Contact an attorney who specializes in life insurance claims to review the policy, gather necessary medical documentation, and help you file an appeal or take legal action.Can a sickness exclusion apply to cancer?
Cancer is commonly covered in life insurance policies, but some policies may exclude coverage if the cancer was diagnosed before the policy's effective date. Review the policy for specifics.How can I challenge a disputed diagnosis in my life insurance claim?
We can help you gather additional medical evidence, work with experts, and challenge the insurer’s decision if they dispute the diagnosis provided by your doctor.What can I do if my life insurance policy has ambiguous language?
If the language of the sickness exclusion is unclear, our team can help interpret the policy terms and potentially argue for a more favorable interpretation based on legal precedents.