Life insurance companies frequently deny claims by pointing to medication use that was never disclosed or was allegedly outside normal medical practice. One increasingly common justification involves off label drug use. Beneficiaries are often stunned to learn that a legally prescribed medication is being used as a reason to withhold life insurance benefits.
Off label prescribing is widespread in modern medicine. It is lawful, common, and often medically appropriate. Yet insurers sometimes treat off label use as evidence of misrepresentation, risky behavior, or undisclosed health conditions. In many cases, these denials do not hold up under legal scrutiny.
What Off Label Drug Use Actually Means
Off label use refers to prescribing an FDA approved medication for a purpose other than the specific indication listed on the drug’s label. Physicians routinely prescribe medications off label for pain management, mental health treatment, autoimmune disorders, cancer care, and rare conditions.
This practice is legal and accepted throughout the medical community. The FDA regulates drug approval, not how licensed physicians prescribe medication. A patient using a drug off label is not engaging in illegal conduct or experimental treatment by default.
How Insurers Use Off Label Drug Use to Deny Claims
Life insurance companies may argue that off label drug use proves the insured failed to disclose a serious medical condition, understated the severity of an illness, or misrepresented their health history during underwriting. Some insurers claim that off label prescriptions suggest high risk behavior or unapproved treatment that materially increased the risk of death.
Common denial scenarios include alleging that the medication implies an undisclosed diagnosis, asserting that the insured was being treated for a condition excluded by the policy, claiming the drug caused or contributed to death, or arguing that the insured intentionally withheld information about treatment plans.
These arguments often rely on assumptions rather than facts. A medication does not automatically reveal a diagnosis, and many drugs are prescribed for multiple unrelated conditions.
Why These Denials Are Often Improper
Life insurance policies are contracts that must be interpreted based on their actual language. Most applications ask about diagnosed conditions, hospitalizations, or specific treatments. They do not ask whether a medication is being used on label or off label.
Insurers must prove that any alleged misrepresentation was material and intentional. Off label drug use alone does not satisfy that burden. In addition, insurers frequently lack medical evidence linking the medication to the cause of death.
Courts often reject denials based on speculation, especially when the insured relied on a licensed physician’s medical judgment. Policyholders are not required to second guess their doctors or predict how an insurer might interpret a prescription years later.
The Role of Medical Records and Pharmacy Data
During a claim investigation, insurers may comb through pharmacy records, prescription histories, and medical notes to identify off label use. These records are frequently misread or taken out of context.
Medical charts may list medications without clearly stating the prescribing rationale. Insurers sometimes infer diagnoses that were never made or exaggerate the significance of a treatment that was precautionary or temporary.
A careful review of the full medical file often reveals that the insurer’s conclusions are unsupported or contradicted by the treating physician’s notes.
Legal Challenges to Off Label Drug Denials
Many courts recognize that off label prescribing is a normal part of medical care. Judges often focus on whether the policy language actually requires disclosure of medication use, whether the insured answered application questions truthfully as written, and whether the insurer can establish a direct connection between the medication and the alleged risk.
Incontestability clauses may also limit the insurer’s ability to deny a claim after a policy has been in force for a certain period. Even when misrepresentation is alleged, the insurer must still meet strict legal standards.
What Beneficiaries Should Do After a Denial
A denial based on off label drug use should never be accepted at face value. Beneficiaries should request the complete claim file, including internal underwriting notes, medical reviews, and pharmacy data relied upon by the insurer.
It is critical to compare the denial rationale against the exact wording of the policy and application. Many denials unravel once the insurer is forced to explain how lawful medical treatment violated a contractual obligation.
Protecting Policyholders and Families
Off label drug use is not misconduct, deception, or evidence of wrongdoing. Life insurance companies cannot retroactively redefine medical care to avoid paying benefits.
Denied life insurance claims based on off label prescriptions are often vulnerable to challenge. With a thorough legal and medical analysis, beneficiaries may be able to recover the full death benefit owed under the policy.
We have recently settled claims from: F&G Life; Farmers Insurance; Security Benefit; Securian Financial; and Penn Mutual.