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Our life insurance law firm recently secured a $600,000 settlement in an Accidental Death and Dismemberment claim that Mutual of Omaha initially denied. As with many AD&D cases, the insurer relied on narrow policy language and aggressive interpretation of exclusions to avoid paying a benefit that appeared straightforward to the family. This case is a strong example of how AD&D denials are frequently based on legal overreach rather than clear policy violations and why experienced legal intervention is often necessary to recover benefits.
Why AD&D Claims Are Denied So Frequently
Accidental Death and Dismemberment insurance is one of the most aggressively denied forms of coverage. Unlike standard life insurance, AD&D policies only pay when the insurer determines that death or injury resulted solely from a qualifying accident. That single word, accident, becomes the battleground in most disputes.
Insurance companies routinely deny AD&D claims by asserting that the event falls outside the policy’s definition. Common justifications include allegations that the insured engaged in excluded activities, was impaired by alcohol or drugs, had a contributing medical condition, or failed to meet technical documentation requirements. Even when the death was sudden, unexpected, and violent, insurers often search for any factor that allows them to argue the loss was not purely accidental.
In this Mutual of Omaha case, the denial hinged on a combination of alleged exclusions and disputed causation. Only after litigation pressure did the insurer reverse course and agree to a substantial settlement.
How Insurers Narrow the Definition of “Accidental”
What families reasonably understand to be an accident often does not align with how insurers interpret the term. AD&D policies are drafted with extensive fine print that limits coverage in ways most policyholders never anticipate.
Many policies exclude losses connected to intoxication, prescription medication use, violations of law, certain occupations, or failure to use safety equipment. Others deny claims if a medical condition played any role, even if the condition did not cause the incident. Insurers frequently argue that if a heart condition, seizure disorder, or even fatigue contributed in any way, the death was not accidental under the policy.
This broad discretion allows insurers to deny claims that would otherwise qualify under common sense standards. Legal analysis is required to determine whether the exclusion was properly applied and whether the insurer met its burden of proof.
AD&D Denials Based on Medical Contribution Arguments
One of the most common denial tactics involves asserting that a pre existing or underlying medical condition contributed to the death or injury. Insurers often rely on selective portions of medical records or autopsy findings to argue that the accident was secondary rather than primary.
Courts have repeatedly held that the presence of a medical condition does not automatically defeat an AD&D claim. The key legal question is whether the accident was the predominant cause of death. In many cases, insurers stretch medical evidence far beyond what the facts support. In the Mutual of Omaha matter, expert analysis undermined the insurer’s causation theory and exposed the weakness of its denial.
Alleged Risky Behavior and Application Issues
Insurers also look backward after a claim is filed, attempting to find omissions or misstatements in the original application. They may allege that the insured failed to disclose a hobby, occupation, or medical condition that increased risk. Even when the insurer never investigated these issues during underwriting, they often attempt to rescind coverage after a death.
These arguments frequently fail when challenged. Insurers cannot rely on information they chose not to investigate at the time the policy was issued, especially after accepting premiums and providing coverage. In this case, Mutual of Omaha’s post claim underwriting tactics were a major factor in driving the settlement.
Documentation Demands and Procedural Denials
AD&D claims generate some of the most aggressive documentation requests in the insurance industry. Insurers routinely demand police reports, autopsy findings, toxicology results, emergency response records, employment records, and witness statements. Any perceived inconsistency or delay is used as justification to deny the claim.
Families often struggle to gather this information while grieving. Insurers know this and exploit procedural gaps to build a denial record. Legal representation shifts that dynamic by ensuring evidence is collected, presented, and framed correctly.
How Legal Pressure Changed the Outcome
In the $600,000 Mutual of Omaha case, the insurer initially refused payment despite strong factual support for accidental death. Through a detailed legal challenge that focused on policy language, medical causation standards, and improper reliance on exclusions, the denial became indefensible.
Once confronted with the likelihood of litigation exposure and unfavorable precedent, Mutual of Omaha agreed to settle rather than risk a court ruling. This outcome reflects a broader pattern in AD&D litigation. Many insurers deny first and reassess only when forced to justify their position under legal scrutiny.
Why AD&D Claims Require Experienced Legal Review
AD&D policies are intentionally complex. They are designed to limit payouts and shift the burden onto beneficiaries. Insurers employ teams of adjusters and attorneys whose sole job is to find reasons to deny coverage.
Our firm handles AD&D claims arising from private policies, employer sponsored group plans governed by ERISA, and supplemental riders attached to life insurance policies. We also represent families in denied FEGLI and SGLI cases where accidental death benefits are involved. These claims require a precise understanding of policy construction, causation standards, and federal and state insurance law.
Protecting Your Right to Appeal
AD&D denials often come with strict appeal deadlines. Missing those deadlines can permanently bar recovery, especially in ERISA governed cases. Early legal involvement preserves evidence, prevents damaging admissions, and positions the claim for maximum recovery.
The $600,000 Mutual of Omaha settlement is a clear example of how denied AD&D claims are not final and how insurers frequently pay only after their legal position collapses. If an accidental death claim has been denied, immediate legal review is essential to protect your rights and pursue the full benefit owed.