Dealing with the accidental death of a loved one can be incredibly hard, especially if the person happened to be the main breadwinner of the family. This is precisely why people buy accidental death and dismemberment (AD&D) insurance, as they want to make sure that the financial needs of their loved ones are taken care of in the event of their untimely death or major disability.
Having their AD&D claim denied by the insurance company is the last thing anyone wants to happen, as it can worsen the emotional trauma they are going through. Fortunately, there are several legal options available for those whose AD&D claims have been unfairly denied by their insurance company.
How Does AD&D Insurance Work?
AD&D insurance, as the term indicates, is meant to provide financial support to your family under the following circumstances.
- If you die in an accident
- If you suffer an injury in an accident, which results in the loss or loss of use of an organ or function,
The payout from an AD&D policy might differ based on the injuries you suffer. For instance, if your injuries result in the loss of a limb, you might receive a portion of the policy’s face value, as specified in your policy documents. If, on the other hand, you suffer fatal injuries and die, your family will receive the entire face value amount – commonly referred to as the death benefit.
AD&D policies are usually offered as a rider to traditional life insurance policies. They are also, however, available as stand-alone policies. It is important to understand that virtually anyone can obtain an AD&D Policy regardless of their health condition, and they are NOT expensive.
Under What Circumstances Do Insurance Companies Deny AD&D Claims?
If someone in your family dies or is seriously injured in an accident, if you are named as beneficiary, you must file an AD&D claim with the insurance company. You need to produce all the relevant documents – especially the death certificate, which specifies that the death was indeed accidental.
The problem, however, is that the insurance company might not be convinced that the death was accidental based on the death certificate alone. Depending on the circumstances, they might conduct their own investigation to find out whether the insured’s death or disability was caused by the accident.
If the insurance company has reason to suspect that the death was not entirely accidental, they might deny your claim. For instance, if the insured died as a result of prescription drug overdose, the insurance company might deny the claim – arguing that the insured took the medications contrary to their physician’s instructions.
Similarly, if the insured suffered a heart attack while driving, which caused them to lose control of their vehicle and crash into another vehicle, and if they died as a result of the injuries they sustained in the accident, the insurance company might deny the claim as well. They might argue that the death was caused primarily as a result of the heart attack, which meant the death was not entirely accidental.
Whether you are an AD&D policyholder or a beneficiary, you need to understand that insurance companies have a profit motive. They make money by maximizing the amount of premiums they collect and minimizing the amount of benefits they pay out. This is why they tend to deny AD&D claims whenever they believe they have a reasonable argument that the death was not entirely accidental.
Also, AD&D policies usually have a provision wherein the insurance company is not liable to pay the death benefit under the following circumstances.
- If the insured died of self-inflicted injuries (suicide or attempted suicide)
- If the insured was killed died as a result of the injuries sustained in a violent attack if the insured deliberately put themselves in danger
- If the insured went missing and was declared dead by disappearance
- If the insured died as a result of the injuries they suffered in a declared or undeclared act of war
- If the insured died as a result of the injuries they suffered while serving in the armed forces or in any other international agency
- If the insured died as a result of the injuries they suffered while committing, attempting to commit, or participating in a crime
- If the insured died as a result of a drug overdose or the complications resulting from the intake of drugs, which include narcotics, barbiturates, hallucinogens, amphetamines, sedatives, and other drugs which are prohibited by federal law and cannot be obtained without a prescription
- If the insured died as a result of prescription drug overdose – especially if they self-medicated or if they failed to follow their physician’s instructions
- If the insured died as a result of the injuries they suffered while driving a motor vehicle under the influence of alcohol or drugs
- If the insured died as a result of the complications resulting from a medical procedure – especially if they were informed of the risks involved prior to the procedure
- If the cause of death cannot be determined accurately
- If the death does not occur within a specified time after the injury, usually one year
In addition to this, AD&D insurance policies may exclude deaths caused by skydiving, bungee jumping, car racing, motorcycle racing, and other such high-risk activities.
The rationale behind the exclusion is that when you participate in such an activity, you do so while being aware of the risks involved – including the risk of suffering fatal injuries. So, the insurance company might argue that any injury resulting from such activities or hobbies cannot be considered entirely accidental.
Apart from this, the insurance company might also reject or deny your AD&D claim if you miss the deadline for filing a claim.
Dealing with an AD&D Claim Denial
Under California law, insurance companies have the right to reject or deny an AD&D claim if the insured dies of natural causes or in the event of a policy violation. Unfortunately, many insurance companies tend to deliberately misinterpret the provisions in AD&D policies and deny legitimate claims.
If you believe that your AD&D claim has been denied by the insurance company without any legitimate reason, you should seek the advice of a life insurance attorney who is experienced in dealing with AD&D claim denials.
ERISA and Non-ERISA Claims
If the AD&D coverage in question was provided by the insured’s employer, the claim is subject to the provisions in the Employee Retirement Income Security Act (ERISA), which is a federal law.
It is important to understand that it is much better to buy this insurance privately rather than through your work. That is because if there is a dispute over coverage, a work policy is subject to determination under ERISA, the claim is determined by an administrator and a denial is ordinarily not subject to court review except for abuse of discretion. A private policy may be litigated fully in the courts. You can also sue for bad faith in the case of a private policy, but not in an ERISA policy.
If, on the other hand, it was a personal AD&D policy, your claim is fully protected by state insurance and contract laws.
The Importance of Hiring the Right Life Insurance Lawyer
It is generally not advisable to deal with the insurance company by yourself if there is a dispute. Not only are insurance companies unlikely to change their mind once a claim has been denied, but everything you say to them is recorded and will be used against you if there is a subsequent lawsuit. So, in the event of a dispute, it is essential to a favorable outcome that you engage a life insurance lawyer who has the legal knowledge, experience, and resources to represent you who is experienced with these types of claims.
A life insurance attorney’s responsibilities in an AD&D claim denial case include:
- Reviewing policy documents, medical records, coroner’s report, toxicology records, and other related documents to get a clear picture of the cause of the death
- Consulting physicians, toxicology experts, accident reconstruction specialists, and other experts to confirm the cause of the death
- Gathering the evidence needed to prove that the insurance company acted in bad faith
- Filing appeals with the insurance company, state court, or federal court as and when needed
- Negotiating with the insurance company
- Bringing suit, and if appropriate, a bad faith lawsuit against the insurance company
Trustworthy Accidental Death Claim Denial Lawyer in California
If your AD&D claim is being delayed or has been denied by the insurance company, experienced California life insurance attorney Benjamin Blakeman can help you.
With over 40 years of experience, Benjamin Blakeman is one of the most successful and trusted life insurance attorneys in California today. An expert in interpreting insurance contracts, Blakeman can reliably determine whether your insurance company had a legitimate reason to deny your claim or if it acted in bad faith.
Having worked as a life insurance agent in the past, Benjamin Blakeman is well aware of the tactics that are commonly used by insurance companies to delay and deny legitimate claims. He can see through the legalese, identify the issues, and determine the proper strategy to counter the insurance company’s arguments.
Remember – a denial by the insurance company is not the end of the road. If the insurance company did not have a legitimate reason to deny your claim, their decision can be reversed by filing an appeal, or by a lawsuit. If they acted in bad faith and deliberately deprived you of the benefits you are entitled to, you may also be able to recover attorney’s fees and in some cases, punitive damages as well.
If you are looking for a skilled life insurance attorney to help you with your AD&D claim, you cannot go wrong with Benjamin Blakeman. To find out how California accidental death claim denial attorney Benjamin Blakeman can help you, call Blakeman Law today at 1-866-567-9242 or contact us using our online form.