Accidental Death and Life Insurance

We buy life insurance for just one reason: we want to make sure our loved ones are financially protected when we pass away. We want the life insurance company to pay promptly and without hassle.

The interests of the life insurance company are completely different.

Have you heard of the life insurance company golden rule? It goes like this: the life insurance company collects your gold to invest and make unheard-of financial returns. But when it is time to pay benefits, the insurance company claims that beneficiaries aren’t entitled to them. They will delay, deny, and make it financially difficult for loved ones – because they can.

That’s just wrong. It increases the tragedy and grief of families who rely on insurance companies to do the right thing and pay benefits.

You have made the wise decision to learn more about life insurance and how we can help with the claims process, delayed payments, or a claim denial.

Is There a Difference Between Accidental Death Insurance and Life Insurance?

Yes. It is a bit tricky because accidental death benefits (AD&D) can be part of a regular life insurance policy or a separate policy. That separate policy can be purchased from a life insurance company, an employer, a bank, a credit union, or even through a credit card purchase.

In other words, a life insurance policy covers death from natural causes and accidental death. However, you can purchase additional accidental death and dismemberment coverage, which obligates the insurance company to pay both life insurance benefits and the additional accidental death benefits.

That is why AD&D coverage has been called double indemnity coverage. The beneficiary gets paid twice: once for life insurance benefits and again for accidental death benefits.

It isn’t uncommon for the life insurance carrier to pay the life insurance benefits but deny the accidental death benefits.

How Does a Beneficiary File a Claim for Accidental Death Insurance?

As part of the life insurance and accidental death policy application process, the policyholder is required to designate who will receive the proceeds of the policy. That person or persons are called the beneficiary or beneficiaries.

If the policyholder dies in an accident, the beneficiary of the life and/or accidental death policy will file a claim with the insurance company. An adjuster or claims examiner will be assigned to the claim and will collect documents such as:

• Accident reports
• Statements from any witnesses
• Medical reports from both before and after the accident, including operative records
• Prescription records from both before and after the accident
• Toxicology reports
• Coroner’s reports
• Death certificate

From the moment a claim is filed, the insurance company looks for ways to delay or deny the claim. They are in the business of collecting premiums, not paying claims. They have teams of medical and legal professionals to create claim denials or minimize how much the insurance company pays.

Many unwitting mistakes can destroy a claim from the very beginning. A beneficiary should hire a life insurance attorney before filing a claim to avoid delays or denial.

Coverage Claims Denials at the Application Stage

One of the first things the insurance company does is determine if there is a life insurance policy in force at the time of the policyholder’s death. These are called coverage defenses. Claims are denied right off the bat because:

• The policyholder failed to pay premiums.
• The employer failed to remit the premiums or made a mistake in offering coverage.
• The policy lapsed.
• The policyholder failed to reinstate the policy.
• The policyholder made misrepresentations on the life insurance policy application.
• The policyholder didn’t provide complete information on the life insurance policy application.
• The policyholder didn’t provide the insurability form.
• The policyholder was terminated and didn’t have coverage.
• The policyholder’s employment status changed so there was no coverage.
• The beneficiary didn’t file a claim for benefits on time.

If the claim was denied for any of these reasons, you owe it to yourself to have a free case evaluation to see how we can help.

Once the life insurance carrier determines they can’t deny the claim for lack of coverage, the carrier will then look to see if they can deny the claim on the basis that there was no accident or whether a policy exclusion applies.

Regardless, the carrier’s reasons or justifications for the claim denial aren’t always right. It just means they don’t want to pay an expensive claim. The less the carrier pays, the more they make.

Will the Insurance Company Pay Accidental Death Benefits Immediately?

The insurance company is required to pay benefits within thirty to sixty days of death. However, in reality, the insurance company rarely pays benefits immediately, even when the cause of death is clear. For example, the insured might have died as a result of a brain injury in a single-car accident. That sounds simple, doesn’t it?

The insurance company must gather all records and determine:

1. Whether there was an accident, as defined by the terms of the policy.
2. Whether the death was the direct result of the accident.

The insurance carrier’s first line of defense is claiming there was no “accident.” As the Pennsylvania Supreme Court said in Brennen v. St. Paul F. & M. Ins. Co., 411, 412-13 Pa. 409 (1963):

“Everyone knows what an accident is until the word comes up in court. Then it becomes a mysterious phenomenon… An accident, simply stated, is merely an unanticipated event; it is something which occurs not as the result of natural routine, but as the culmination of forces working without design, coordination, or plan. And the more disorganized the forces, the more confusedly they operate, the more indiscriminately haphazard the clash and intermingling, the more perfect is the resulting accident.”

The second line of defense: let’s say the insured driver had a heart attack, ran into a tree, and sustained a brain injury from which they died. Was the death the result of the heart attack or the brain injury? The carrier may deny the claim based on the sickness exclusion in the policy, arguing the heart attack was caused by cardiac disease.

The insurance company won’t rely solely on medical records or the death certificate. They will conduct an “independent” investigation into whether the death was accidental and not due to natural causes.

It is not unusual for an insurance company to claim they don’t have enough information to make a decision and delay the claim. Worse yet, they may deny the claim on the basis that they lack sufficient information, that their “independent” investigation reveals the death was not accidental, or that AD&D benefits are not due because of a policy exclusion.

The Policy Exclusion “Gotcha”

Even if the beneficiary can prove the death was accidental, the insurance company can still deny AD&D benefits by claiming the death is excluded under the policy. Many policies will not pay AD&D benefits if the death was caused by:

• Injury sustained as a result of being legally intoxicated.
• Injury sustained while operating a motor vehicle while legally intoxicated.
• Injury sustained as a result of attempting to or committing a felony.
• Injury sustained while voluntarily taking drugs prohibited by federal law without a prescription, including sedatives, narcotics, barbiturates, amphetamines, or hallucinogens, unless taken as prescribed or administered by a licensed physician.
• Injury sustained while riding in any aircraft as a pilot, crew member, student pilot, flight instructor, or examiner.
• Injury sustained while serving full-time in the armed forces of any country or international authority.
• War or acts of war, whether declared or undeclared.
• Sickness or mental infirmity.
• Intentional self-inflicted injury, suicide, or attempted suicide, whether sane or insane.
• Death occurring in a foreign country.

Common Reasons for Claims Denial Based on Policy Exclusions

Life insurance policies are written in ways that allow insurance companies to deny claims. They use policy language to argue there was no accidental death or that benefits are not payable due to some exclusion. Common reasons for denial include:

• Death due to sickness
• Death was not accidental
• Death was accidental but contributed to by a sickness
• Death resulted from intoxication
• Death resulted from taking prescription drugs not prescribed by a doctor
• Death resulted from taking illegal drugs
• Death resulted from autoerotic asphyxiation
• Death resulted from assault or murder
• Death resulted from violating the law or participating in a misdemeanor or felony at the time of death

Do any of these sound familiar?

How to Handle a Delayed Decision or Appeal a Denied Accidental Death Claim

Other grounds for denial may result from the insurance carrier’s misunderstanding of medical issues, misinterpretation of policy terms, or misapplication of policy exclusions.

Regardless of the reason, you need an experienced life insurance attorney to help you get the benefits you deserve. Some deadlines are as short as sixty to ninety days from the claim denial.

It is crucial to hire an AD&D attorney who:

• Can read and understand medical reports.
• Understands the medical and legal issues that arise in determining the cause of death.
• Can retain and work with medical experts, including toxicologists and coroners.
• Works with police and accident reconstruction experts.

Many times, the insurance carrier’s denial can be challenged based on accident reconstruction experts and medical opinions that differ from the insurance company’s.

Additionally, insurance companies often misinterpret or misapply policy language to justify a denial. This policy “hocus pocus” can be challenged in court. Courts can review the plan and ordinary language of the policy, and prevent the carrier from using ambiguous language to deny a claim.

Talk to an Experienced Accident Death Attorney

Regardless of why the insurance company has delayed or denied benefits, the Law Office of Nancy L. Cavey is here to review the policy, police reports, witness statements, medical records, and the carrier’s letters and give you a straight answer. We aren’t afraid to take on life insurance companies that wrongfully delay or deny benefits, and we litigate AD&D claims denials in both state and federal courts.

Don’t let the insurance carrier profit from a wrongful denial. Your loved one paid years of premiums for just one reason: to protect you and your family when they passed away.

Call 727-894-3188 for a free thirty-minute consultation. We work on a competitive contingency fee basis and don’t get paid unless we recover benefits.

We will:

• Listen to you.
• Review the policy.
• Review all important documents.
• Review the carrier’s letters.
• Answer all of your questions.
• Explain all of your options.
• Explain what it will cost.

No Legal Fees Unless We Win Your Case

Our fee is simple. We work on a contingency fee basis, which means we don’t get paid unless we collect the life insurance benefits that are delayed or denied. We charge a fee agreed upon when we are hired. The fee is flexible, based on whether the claim is delayed or denied and how medically or legally complex the case might be. We guarantee you will be comfortable with the fee.

Don’t let the accidental dismemberment insurance company rob you of your peace of mind and financial security. Call today for a complimentary consultation.