MetLife issues a large number of accidental death and dismemberment policies through employer benefit plans and voluntary workplace insurance programs. These policies are designed to pay an additional benefit when death or serious injury results from an accident rather than illness.
Despite this purpose, many beneficiaries encounter problems when submitting AD&D claims to MetLife. The company may conclude that the death does not meet the policy’s definition of an accident or argue that another factor contributed to the loss. When that happens, the claim may be denied even though the family believes the circumstances clearly involved an accident.
Attorney Christian Lassen represents beneficiaries nationwide in disputes involving denied accidental death and dismemberment claims.
Understanding How AD&D Coverage Works
AD&D insurance differs from traditional life insurance. Standard life insurance pays the benefit when the insured dies from almost any cause, subject to limited exclusions. AD&D policies, by contrast, require proof that the death resulted directly from an accidental event.
This distinction is the source of many disputes. Even when an accident occurred, insurers sometimes argue that a medical condition, intoxication, or other contributing factor removes the claim from AD&D coverage.
Common Reasons MetLife Denies AD&D Claims
MetLife denial letters often rely on specific policy language describing what qualifies as an accidental death. Several issues frequently appear in AD&D disputes.
Cause of death disputes
One of the most common denial reasons involves disagreements about the cause of death. MetLife may argue that the death resulted from illness or a medical event rather than an accident.
Contributing condition arguments
Many AD&D policies contain language stating that the accident must be the direct cause of death independent of sickness or disease. Insurers sometimes rely on medical records to argue that a health condition contributed to the outcome.
Intoxication or drug related exclusions
If toxicology results show alcohol or certain substances in the insured’s system, MetLife may attempt to invoke an intoxication exclusion. These disputes often depend on whether the substance actually caused or contributed to the death.
Activities classified as high risk
Some policies contain exclusions for hazardous activities. Denials sometimes arise when the insurer claims the accident occurred during an activity excluded by the policy.
The Role of Medical and Forensic Evidence
AD&D disputes frequently turn on the interpretation of medical evidence. Insurers may rely on medical records, autopsy findings, or toxicology reports to support their conclusions about the cause of death.
Because these records can be interpreted in different ways, the details of the incident often matter. Witness accounts, police reports, and accident investigations may provide context that contradicts the insurer’s interpretation.
Careful review of the medical evidence can reveal whether the insurer’s conclusion about the cause of death is supported by the full record.
Employer Sponsored AD&D Policies and ERISA
Many MetLife AD&D policies are issued through employer benefit plans. These plans are commonly governed by federal law under the Employee Retirement Income Security Act.
Under ERISA, beneficiaries typically must submit a written appeal if a claim is denied. The appeal allows the claimant to provide additional documentation and challenge the insurer’s reasoning.
Because courts reviewing ERISA disputes often rely on the evidence submitted during the appeal, preparing a detailed appeal can be an important step in challenging an AD&D denial.
Documents That May Help Challenge an AD&D Denial
Beneficiaries who receive a denial can request records related to the insurer’s decision. These documents often reveal how the claim was evaluated.
Relevant materials may include:
The AD&D policy and benefit plan documents
The insurer’s internal claim file
Medical and toxicology reports relied on by the insurer
Accident reports or witness statements
Correspondence related to the claim investigation
Reviewing these records can help determine whether the denial is based on incomplete or disputed information.
Legal Help With MetLife AD&D Claim Denials
Accidental death and dismemberment claims can involve complex questions about policy definitions and medical causation. Beneficiaries may have options to challenge a denial if the insurer’s interpretation of the evidence is questionable.
The Lassen Law Firm focuses exclusively on life insurance and accidental death disputes nationwide. Attorney Christian Lassen has more than 25 years of experience representing beneficiaries in denied and delayed insurance claims.
If MetLife has denied an AD&D claim, legal review can help determine whether the insurer’s decision can be challenged.