One of the most confusing life insurance claim denials occurs when the employer approved an employee’s coverage election, but the insurance company later claims the coverage was never valid because evidence of insurability was not completed or approved.
Families often discover this problem only after a claim is filed. The employer’s records may show that the employee elected and received the coverage, while the insurer claims that the underwriting requirement was never satisfied.
Attorney Christian Lassen represents beneficiaries nationwide in denied and delayed life insurance claims.
What Evidence of Insurability Means
Evidence of insurability is the medical underwriting process required when an employee requests life insurance coverage above certain limits in a group policy.
Employees may need to complete a health questionnaire or provide medical information before the insurer approves the additional coverage.
In many employer life insurance plans, coverage up to a certain amount is issued automatically. Coverage above that amount requires evidence of insurability approval.
How the Conflict Happens
This dispute often begins during open enrollment or after a qualifying life event. The employee selects a higher level of coverage through the employer’s benefits system.
The employer may process the election and treat the employee as covered. However, the insurance company may later claim that the employee never completed the evidence of insurability requirement.
When the insured dies, the insurer may deny the increased coverage.
Situations That Lead to This Denial
These disputes commonly arise when the enrollment process and underwriting process are handled by different systems.
Examples include:
The employer approved the coverage election in the HR system
The employee believed the election was complete
The insurer never received the underwriting forms
The insurer received the forms but never issued an approval decision
In each of these situations, the employer and insurer records may tell different stories.
Why Payroll Deductions Often Continue
Employees and families are often surprised because payroll deductions for the higher coverage amount may continue for years.
From the employee’s perspective, the coverage appears active. Pay stubs show premiums being deducted, and benefit summaries may reflect the elected coverage amount.
The insurer may later argue that payroll deductions do not create coverage if the evidence of insurability requirement was never satisfied.
Conflicting Records Between Employer and Insurer
These cases frequently involve conflicting records.
For example:
The employer’s HR system may show that the employee elected and received approval for the higher coverage amount.
At the same time:
The insurer’s records may show that underwriting approval was never granted.
These discrepancies often lead to claim denials and sometimes litigation.
The Role of Evidence of Insurability Forms
Evidence of insurability forms usually ask for medical history and other health information. The insurer reviews this information to decide whether the additional coverage will be approved.
If the insurer never receives the forms, or if the forms are incomplete, the insurer may later claim that the higher coverage never took effect.
However, disputes often arise over whether the employee was properly informed about the requirement.
Documents That Often Determine the Outcome
Several types of records can become important when a denial involves evidence of insurability.
These may include:
Open enrollment confirmations
Benefits portal screenshots
Emails from HR about coverage approval
Evidence of insurability forms and submission records
Payroll records showing premium deductions
The insurance company’s underwriting notes
These documents may reveal whether the employee attempted to complete the underwriting requirement.
ERISA Appeals and Administrative Records
Most employer sponsored life insurance plans fall under federal ERISA law. When a claim is denied, the administrative appeal process becomes the primary opportunity to submit evidence.
During the appeal, beneficiaries may present documentation showing:
The employer approved the coverage election
The employee believed coverage was active
Payroll deductions were taken for the higher amount
The evidence of insurability requirement may not have been properly communicated
The administrative record developed during the appeal often becomes the foundation for any later court review.
Why Employees Rarely Detect the Problem
Employees often assume that once their employer confirms coverage in the benefits system, the coverage is active.
Because underwriting requirements are handled behind the scenes by the insurer, employees may never realize that additional approval was required or missing.
The discrepancy between employer records and insurer records may only become apparent after a claim is filed.
Legal Help With Evidence of Insurability Denials
Life insurance claim denials involving evidence of insurability often involve administrative errors, missing records, or communication breakdowns between the employer and insurer.
The Lassen Law Firm focuses exclusively on life insurance disputes nationwide. Attorney Christian Lassen has more than 25 years of experience representing beneficiaries in delayed, denied, and disputed life insurance claims.
If a life insurance claim was denied because the insurer says evidence of insurability was never approved, legal review may help determine whether the denial resulted from an administrative failure rather than a valid underwriting decision.