Accidental Death and Dismemberment policies frequently include alcohol related exclusions that insurers rely on when denying claims. These provisions are often broadly written, allowing insurers to argue that alcohol contributed to the death even when the underlying event was clearly accidental.
In one case handled by our firm, a $150,000 Prudential AD&D claim was initially denied based on an alcohol exclusion. After challenging the denial, the claim was successfully resolved.
Attorney Christian Lassen focuses exclusively on life insurance and AD&D disputes nationwide.
The Accident and Initial Claim
The insured died in an accident that triggered coverage under an employer sponsored AD&D policy issued by Prudential. The beneficiary submitted a claim seeking payment of the accidental death benefit.
During the claim review process, the insurer obtained toxicology records from the medical examiner. The toxicology report showed the presence of alcohol in the insured’s system.
Based on this information, Prudential denied the claim.
Prudential’s Alcohol Exclusion
Many AD&D policies contain exclusions stating that benefits may be denied if alcohol intoxication contributed to the accident. Insurers sometimes rely heavily on toxicology results when applying these provisions.
In this case, Prudential relied on policy language stating that benefits could be excluded if the insured was under the influence of alcohol at the time of the accident.
The insurer concluded that the alcohol level in the toxicology report triggered the exclusion and refused to pay the $150,000 accidental death benefit.
Challenging the Denial
The denial raised several important questions regarding how the alcohol exclusion applied to the facts of the case.
Issues that often arise in alcohol related AD&D denials include:
Whether intoxication actually caused the accident
Whether the policy requires proof of causation
Whether the alcohol level meets the definition used in the policy
Whether other evidence contradicts the insurer’s conclusion
In many cases, insurers assume that the presence of alcohol alone is enough to deny coverage.
Examining the Cause of the Accident
A key issue in this case involved the cause of the accident itself. The circumstances surrounding the death showed that the fatal event resulted from an external accident rather than from alcohol consumption.
When reviewing AD&D claims, it is important to examine the full set of records, including:
Accident reports
Medical examiner findings
Toxicology reports
Witness statements
Emergency response reports
These records can help determine whether alcohol actually played a causal role in the accident.
Reconsideration of the Claim
After the denial was challenged and the circumstances of the accident were reviewed, the insurer reconsidered the claim. The case was ultimately resolved for the full $150,000 accidental death benefit.
Alcohol exclusions in AD&D policies are often interpreted broadly by insurers, but the specific facts of the accident and the policy language can play a major role in determining whether the exclusion applies.
Alcohol Exclusions in AD&D Policies
Alcohol related exclusions are one of the most common reasons AD&D claims are denied. However, these provisions do not automatically apply in every case where alcohol is present.
Key issues often include:
Whether alcohol actually caused the accident
Whether the policy requires proof of intoxication
Whether the toxicology results meet the policy definition
Whether the accident would have occurred regardless of alcohol
Careful review of the policy and the accident evidence is often necessary to determine whether the denial is justified.
Legal Help With Denied AD&D Claims
AD&D claim denials frequently involve complex questions about the cause of death and how policy exclusions should be interpreted. Insurers often rely on toxicology results and policy language to deny benefits, even when the circumstances of the accident are disputed.
The Lassen Law Firm focuses exclusively on life insurance and accidental death disputes nationwide. Attorney Christian Lassen has more than 25 years of experience handling denied life insurance and AD&D claims.
If an AD&D claim has been denied based on an alcohol exclusion, legal review may help determine whether the denial can be challenged.