AD & D Claim Denied

Denied AD&D Life Insurance Claims: How Our Lawyers Can Help You Recover Your Benefits

If your Accidental Death and Dismemberment (AD&D) life insurance claim has been denied, our experienced life insurance lawyers are here to help. We serve clients in all states and offer a free consultation with no fee unless we win. If you've been wrongfully denied benefits, our legal team is ready to fight for the compensation you deserve.

Understanding AD&D Life Insurance Coverage

Accidental Death and Dismemberment (AD&D) insurance, often referred to as “double indemnity” coverage, is designed to provide financial security in the event of an accident that results in death or serious bodily injury. This specialized insurance policy can be purchased as a rider to a traditional life insurance policy or offered as a supplemental benefit through an employer. It is specifically meant to offer additional financial protection beyond the standard life insurance coverage, often at a more affordable premium, making it an attractive option for individuals in hazardous professions.

AD&D insurance provides a financial safety net for the insured’s beneficiaries if the insured dies due to an accident or suffers severe dismemberment. The benefit amount for death is typically twice the face value of the insured’s standard life insurance policy, hence the term “double indemnity.” It’s important to note that AD&D policies generally cover only accidents that are deemed “accidental” by the insurer’s standards, and this coverage may come with certain exclusions and limitations.

For many individuals, particularly those who are the primary breadwinners in their families, having an AD&D policy can offer peace of mind. It ensures that their loved ones are financially supported in the event of an unforeseen tragedy. Additionally, those working in dangerous professions, such as construction workers or emergency responders, may find AD&D insurance to be a more cost-effective alternative to traditional life insurance, providing them with crucial coverage at a reasonable price.

What Does AD&D Insurance Cover?

AD&D insurance covers a wide range of accidental events, including fatal accidents and dismemberments resulting from unforeseen incidents. The key benefit is that it pays out the policy’s designated sum to the beneficiaries of the deceased insured individual or the insured individual themselves if they sustain qualifying injuries.

The coverage includes:

  • Accidental Death: This includes fatalities from unexpected events like car accidents, falls, drowning, and injuries sustained from incidents involving machinery or equipment. These claims must meet the insurer’s definition of an accidental death.

  • Dismemberment: This includes compensation for the loss of limbs, eyesight, hearing, or speech caused by an accident. The amount of compensation depends on the severity of the dismemberment, with the full payout typically reserved for total loss of a limb or key bodily function.

What Qualifies as an "Accidental Death"?

Under an AD&D policy, an accidental death is typically defined as a death resulting from an unexpected event that is not caused by the insured’s intentional actions. However, each insurance company may have specific guidelines that define what constitutes an accidental death. In general, the insured’s death must meet the following conditions:

  • It must be accidental: The event leading to the death should have been unforeseen and unintentional.

  • Exclusions may apply: Deaths resulting from suicide, attempted suicide, criminal activity, or self-inflicted injuries are usually not covered under AD&D policies. Many policies also exclude deaths due to natural causes or illness, such as heart attacks, strokes, or diseases.

Importantly, while the death does not need to be instant, the death must typically occur within a specified period after the accident (often three to six months). Some states, such as Pennsylvania, have laws that prevent insurers from imposing rigid timeframes on the death qualification after an accident. Therefore, if you are in a state that does not permit such limitations, it's crucial to consult with a lawyer to understand your rights.

What is Considered Dismemberment?

Dismemberment under AD&D policies refers to the loss or permanent impairment of specific body parts or vital functions. For instance, if an individual loses a limb, sight, or hearing due to an accident, they are eligible for compensation under their AD&D policy.

Common dismemberment injuries that qualify for coverage include:

  • Loss of limbs (arms, legs, hands, feet)

  • Loss of fingers or toes

  • Loss of eyesight, hearing, or speech

The payout for dismemberment injuries is typically a percentage of the policy's face value. For instance, the loss of a limb might entitle the insured or their beneficiaries to a higher percentage of the policy’s total benefit than the loss of a finger. Policyholders should carefully review their insurance agreement to understand the specific compensation for each type of injury.

Common Exclusions from AD&D Coverage

As with any insurance policy, AD&D coverage comes with exclusions. These exclusions typically prevent certain types of injuries or deaths from qualifying for benefits. Common exclusions in AD&D policies include:

  • Suicide or attempted suicide: Most policies explicitly exclude coverage for suicides or self-inflicted harm.

  • Illness or natural causes: Deaths due to heart attacks, strokes, cancer, or other natural causes are generally excluded.

  • Extreme sports and hazardous activities: Death or dismemberment resulting from high-risk activities, such as skydiving, car racing, or bungee jumping, is often excluded.

  • Intoxication: If the insured was under the influence of drugs or alcohol at the time of the accident, the claim may be denied.

  • Acts of war or military service: Deaths occurring in connection with war or military action are typically excluded.

  • Criminal activity: If the insured was engaging in illegal activities at the time of the accident, the claim may be voided.

Policyholders should thoroughly review their policy to understand the exclusions and limitations that may apply to their AD&D coverage.

Why Are AD&D Claims Denied?

While AD&D insurance is intended to provide crucial benefits, many claims are wrongfully denied. Insurance companies often use a variety of tactics to avoid paying out on claims, including:

  • Policy Lapse: If the insured missed premium payments and the policy lapsed before the accident occurred, the insurer may deny the claim.

  • Criminal Activity: If the insured was involved in criminal activity at the time of the accident, the insurer is likely to reject the claim.

  • Murder by a Beneficiary: If the beneficiary is found to have caused the insured’s death, the insurance company will investigate and deny the claim.

  • Fraudulent Information: Misrepresentation or omission of important information during the application process can be grounds for a claim denial.

  • Undisclosed Medical Conditions: Some insurers argue that pre-existing medical conditions contributed to the accident, giving them grounds to deny benefits.

When an insurer denies a claim, beneficiaries have the right to appeal and challenge the decision. In many cases, a legal expert can help clarify why the claim was denied and assist with gathering additional evidence to overturn the denial.

How Can Our AD&D Lawyers Help?

If your AD&D claim has been denied, our experienced life insurance attorneys are here to help. We have extensive experience handling denied AD&D claims, and we understand the complex nature of these policies. Our legal team will investigate your case, review the terms of your policy, and work with experts to gather the evidence needed to challenge the denial. We offer a free consultation to discuss your case and will not charge any fees unless we successfully recover compensation for you.

Cases

Case 1: Overturning a Denied AD&D Claim Due to a Misinterpreted "Accident" Definition

Mr. Jenkins, a warehouse manager in his 40s, tragically passed away in a workplace incident. His family filed a claim under his AD&D policy, but the insurance company denied the claim, arguing that the cause of death did not meet the definition of an "accident" under the policy terms. The insurer argued that Mr. Jenkins’ death, caused by a heavy piece of equipment falling on him, was not truly accidental because he was “negligent” in not following proper safety protocols, which led to the incident.

The family was confused, as Mr. Jenkins had always followed safety guidelines and had been a model employee. We thoroughly reviewed the AD&D policy and discovered that the insurer had misapplied the policy’s definition of “accident.” According to the policy, an accident could involve unforeseen, unintentional events, and negligence alone didn’t disqualify coverage.

We presented clear evidence that Mr. Jenkins’ death was a tragic accident, not caused by negligence, and highlighted the safety protocols in place at his workplace that he followed. Our team worked with workplace safety experts to ensure that all procedures were adhered to and that the incident was indeed an accident as defined by the policy.

After careful review, the insurer reversed their decision and approved the full AD&D payout. The Jenkins family received the financial support they were entitled to, which helped them cope with their loss and secure their future. This case underscored the importance of ensuring that an insurer correctly interprets policy terms, especially when they attempt to reclassify events as anything other than accidents.

Case 2: Challenging an AD&D Claim Denial Based on Pre-Existing Health Conditions

Ms. Carter, a 50-year-old teacher, faced a devastating situation when her husband, Mr. Carter, a long-time construction worker, passed away due to an accident at work. The insurance company denied her claim under the AD&D policy, citing a pre-existing health condition. They argued that her husband had a history of high blood pressure, and that his health condition contributed to the fatal accident, making it ineligible for an AD&D payout.

Ms. Carter knew that her husband had managed his health carefully, and his blood pressure had never caused any major issues before. We conducted a detailed review of his medical history and the circumstances surrounding the accident. After speaking with his doctor, we confirmed that his high blood pressure was under control and had not contributed to the accident. Furthermore, his cause of death—being struck by a falling object—was unrelated to any health condition.

We filed an appeal with the insurer, providing medical documentation and expert opinions to refute the insurer’s claims. We argued that while his health condition existed, it had not contributed to the incident in any way. The insurer reviewed the evidence and reversed their decision, ultimately approving the full AD&D claim payout.

This case highlighted how important it is to scrutinize an insurer’s reasoning when they attempt to link a pre-existing condition to an accident, as health conditions are often used as a convenient excuse for a denied claim. Our expertise in understanding medical records and AD&D policies helped ensure that Ms. Carter received the support she deserved.

Case 3: Contesting a Denial Due to "Voluntary Risk" Exclusion

Mr. Harrison, a passionate mountaineer, tragically passed away while climbing a mountain during an expedition. His family filed a claim under his AD&D policy, but the insurance company denied the claim, citing a "voluntary risk" exclusion. The insurer argued that Mr. Harrison had taken part in a dangerous activity (mountain climbing), which fell outside the scope of what was covered under the AD&D policy.

However, Mr. Harrison had taken all necessary precautions during his climb. He was an experienced mountaineer with years of training, and he had even purchased additional coverage for extreme sports. The insurer’s reasoning seemed to hinge on a vague interpretation of what constituted “voluntary risk” in their policy.

We carefully reviewed the terms of Mr. Harrison’s policy and discovered that while some extreme activities were excluded, mountaineering was explicitly covered under the policy’s addendum for high-risk activities. We also provided a breakdown of Mr. Harrison’s meticulous safety measures and professional certifications, demonstrating that he had adhered to all guidelines designed to minimize risk.

After we presented this information, the insurer acknowledged their error and reversed their denial. The AD&D payout was made in full, helping the Harrison family manage their financial needs during a difficult time. This case highlighted the importance of interpreting the fine print of high-risk exclusions and ensuring that insurance companies honor their coverage agreements.

Case 4: Denial Based on Alleged Intentional Harm – Reversing the Decision

Ms. Robinson, a young widow, was heartbroken when her husband, Mr. Robinson, passed away in a tragic car accident. The couple had always relied on the AD&D policy to protect their family, but the insurance company denied her claim, arguing that Mr. Robinson had been involved in reckless driving, and that his actions amounted to intentional harm, which was excluded from coverage.

Ms. Robinson was adamant that her husband had not been reckless. The accident occurred when a tire blew out unexpectedly, and his car lost control. However, the insurer labeled it as “reckless driving,” claiming that Mr. Robinson was engaging in risky behavior, such as speeding, before the accident.

We conducted a thorough investigation into the incident, including speaking with witnesses, reviewing accident reports, and obtaining expert testimony about the tire failure. It was clear that the accident was caused by a mechanical failure, not any reckless behavior on Mr. Robinson’s part. We presented this evidence to the insurer, explaining that the accident was entirely unintentional and should not be classified as an exclusionary event.

The insurer re-evaluated the case and reversed their decision. Ms. Robinson received the AD&D payout in full, which was critical for supporting her and her children during their grief. This case showed how insurers sometimes attempt to deny claims by labeling accidents as intentional or reckless, and how challenging those decisions with the proper evidence can lead to a positive outcome.

Case 5: Denied AD&D Claim Based on Failure to Meet Notification Deadline

Mr. Powell, a 60-year-old retiree, had purchased an AD&D policy to provide security for his family. When he tragically passed away in an accident involving a fall at home, his family immediately filed a claim. However, the insurer denied the claim, arguing that the notification of his death had been submitted past the required deadline. The policy stipulated that claims must be filed within 90 days of the incident, and the insurer argued that the claim was filed after the deadline.

Ms. Powell, his widow, had been emotionally overwhelmed and had not submitted the paperwork as quickly as the insurer required. However, we investigated the circumstances and discovered that the delay in filing was caused by confusion on the insurer’s website and miscommunication from their customer service team. We also found that the insurer had failed to provide adequate instructions on how to submit the claim online.

We argued that the insurer had not made reasonable accommodations for the process and that the delay was not the fault of the policyholder. We presented the facts, including screenshots of the website and communication logs, showing the obstacles faced by the family during the claim submission process.

After a thorough review, the insurer acknowledged the issues and allowed the claim to proceed, paying out the full AD&D benefit. This case highlighted how sometimes insurers use technicalities like missed deadlines to deny claims, even when the delay is not due to the fault of the beneficiary.

Conclusion: Ensuring Justice for Denied AD&D Claims

Each of these cases illustrates the challenges and complexities involved in contesting denied AD&D claims. Whether it's a misinterpretation of policy terms, unfair exclusion clauses, or missed deadlines, we have successfully helped clients recover the financial support they were entitled to. These cases demonstrate the importance of understanding the specifics of an AD&D policy and ensuring that all claim denials are thoroughly examined for potential errors or misapplications.

If you or your family has had an AD&D claim denied, it’s essential to seek professional help. With the right expertise, many denied claims can be overturned, ensuring that you receive the benefits your loved one worked hard to secure. Contact us today if you need assistance with your AD&D claim—we are here to help guide you through the process and fight for the compensation you deserve.

Written by: Attorney Christian Lassen, founder of Lassen Law Firm, a national leader in handling life insurance claims, having secured hundreds of millions in settlements for clients nationwide. With 24 years of experience, Mr. Lassen specializes in resolving delayed and denied life insurance claims. He is a certified life member of the Million Dollar Advocates Forum and Multi-Million Dollar Advocates Forum, recognition given only to attorneys who have won million- and multi-million-dollar verdicts and settlements. A top 1% lawyer in the U.S., Mr. Lassen is dedicated to both his clients and community, supporting various charities, especially those focused on children with cancer.

Sources

The NAIC emphasizes that insurers must clearly define what qualifies as an “accidental” death and provide specific reasons for denial. The Insurance Information Institute explains that disputes commonly arise when the cause of death falls into a policy gray area or occurs outside the policy’s coverage scope. For employer-provided AD&D plans, the U.S. Department of Labor outlines the process to appeal under ERISA protections.