Life Insurance Lawyer Colorado

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It pays to fight denial of an AD&D claim

Life insurance companies wrongfully deny death and dismemberment claims all the time

Sometimes it is a wonder that life insurance companies still offer Accidental Death & Dismemberment (“AD&D”) riders to traditional life insurance policies. After all, the AD&D riders typically double or triple the death payout, which is a very expensive prospect for the insurance company.

Accordingly, life insurers have made a pattern and practice of denying AD&D claims on the basis that the insured’s death was caused by something other than an accident – even where the coroner’s report and other medical evidence establishes the accidental nature of the death. This is especially true when the death doesn’t immediately follow the accident – cases where death comes after days or weeks of intervening medical care.

That was certainly the life insurance company’s tactic in the case we’ll examine in this article. Fortunately, the insured’s beneficiary hired lawyers specializing in the wrongful denial of life insurance and AD&D claims. As a result, they ended up getting the full benefit that was intended for them.

A simple game of basketball

This case involves the tragic death of an otherwise healthy, 31 year-old man named Tim. Tim was employed by a sanitation company that provided him with a comprehensive benefit package. Among those benefits were a life insurance policy worth $50,000, with an AD&D rider worth $100,000. Tim named his mother, Jean, as the beneficiary under the policy, though he never thought in a million years she would need to make a claim under that policy during her lifetime.

In a twist of fate that would alter the course of his family’s life, Tim went out with some co-workers in January 2014. The men decided to hit the local gym for a game of pick-up basketball. During the game, Tim went up for a rebound, came down awkwardly on his left leg, and ended up tearing his Achilles tendon in his left ankle.

The next day, he was seen by an orthopedic surgeon who immediately recognized that Tim needed surgery. The surgery was scheduled for four days later. Two days after the office visit, however, Tim went back in to see the surgeon on an emergency basis. His ankle had swelled even further and he was experiencing even greater pain and sensitivity in his lower leg. The surgeon told him to elevate and ice the ankle and to proceed with surgery as planned.

Two days later, Tim had what was believed to be a successful surgery and was released from the hospital the next morning. Everything seemed to be going fine until two days following the surgery, when Tim experienced cardiac arrest and died. It was a shock to everyone in his life.

An autopsy report showed that Tim had developed a blood clot in or around his injured ankle, a condition known as Deep Vein Thrombosis (“DVT”). At some point, the clot had come loose, travelled to his heart, causing the cardiac arrest. The report noted that DVT can be the result of injury or surgery.

Several weeks following his death, Jean made a claim for death benefits under Tim’s life insurance policy and his AD&D rider.

The life insurer claimed the accident didn’t cause the death

The life insurance company was quick to deny Jean’s claim under the AD&D rider. The insurance adjuster claimed that Tim’s DVT was more likely the result of the surgery than the underlying injury to the ankle. Because the surgery was not an “accident,” the insurance company refused to pay the additional $100,000 benefit.

This didn’t sit right with Jean. After all, without the accident that caused his ankle injury, Tim never would have had the surgery. Confused, Jean reached out to a local attorney who specializes on the wrongful denial of life insurance claims. He reviewed Tim’s policy, the relevant medical records, and the claim denial letter and suggested that Jean take the life insurance company to court. That’s just what she did.

The case made its way all the way up to the United States Court of Appeals for the Seventh Circuit. Ultimately, that body agreed with Jean’s initial instincts about the case. The court ruled that while the life insurance company had presented some evidence that surgery can cause DVT generally, it provided no evidence that the ankle surgery caused DVT in Tim’s case. Moreover, the court found it highly relevant that Tim had complained of increased pain, swelling, and sensitivity in that ankle prior to the surgery – all symptoms that could indicate Tim’s blood clot existed prior to the surgery.

Additionally, the court found it highly persuasive that there would have been no surgery if there had been no accident. Viewed in that light, the accident was the originating cause of death, even if the surgical procedure intervened in Tim’s health condition. The court thus ordered the life insurance company to pay Jean the full $100,000 AD&D payout, with interest from the time of Tim’s death.

This case presents a perfect example of the types of games life insurance companies play in trying to avoid AD&D payouts. It is not unusual at all for them to grasp onto some intervening medical treatment that happened between the accident and the death and to claim that such treatment was the actual cause of death. Of course, they do this because if they can blame something other than the accident, they may get away with not paying on the rider.

As attorneys who specialize in the wrongful denial of life insurance claims, we see this tactic used by the insurance companies all the time. However, we’re well aware of cases like Tim’s where the court has found the accident to be the ultimate cause of death. Indeed, we have a very successful track record in these types of cases. If you are a beneficiary who has had an AD&D claim denied based on similar reasoning, please call us today. We’re here to help.