What is an Accidental Death and Dismemberment Policy?

Accidental death insurance policies are designed to offer financial support to beneficiaries after the death of policyholders in case of an accident. But mostly accidental death and dismemberment claims get delayed or denied just like many other life insurance policies. 

The reason behind denial or delay is that the insurer has several limitations and exclusions that exclude accidental deaths from policy coverage. In this blog post, we have tried to explain everything you need to know about accidental death and insurance claims. We will also cover different reasons for the denials and what to do after a denied claim. Keep reading for the answers you want to know! 

Denied Accidental Death Claims: How Can Life Insurance Companies Refuse to Pay Out?

When a beneficiary of accidental death insurance files a claim, the claim department of the insurance company starts an investigation about the cause of death. They review the death certificate of the insured. Moreover, they also go through any medical report, accident or police reports, and the health records of the deceased person. 

If the medical report or death certificate shows that death is due to a car accident or slip-and-fall fatality, still the insurance company is not responsible for the death benefit. Along with an accident, a medical condition may also contribute to the death of the insured and the insurance policy does not cover that death. Most of the denied accidental death claims are due to any pre-existing medical condition of the policyholder. 

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What are the conditions you have to fulfill to get the death benefit of accidental death insurance?

The following are the conditions mentioned that bind a life insurance company to pay an accidental death and dismemberment claim: 

Death does not fall within the limitation: Most insurers deny it because the death was excluded from policy coverage. It is one of the most common reasons the insurer will not pay out the death benefit. So, it’s advisable to check all the terms and conditions of the policy before getting it. 

Death must be followed by an accident: Death should be due to a reason that is covered by the insurance policy and not any other cause is involved. For instance, if the insured died due to a heart attack while skydiving that’s a fatal accident, it is not covered by the insurer. The insurance company will deny the claim because the death was due to a heart attack, a natural cause not covered by this policy type. 

A certain time after the accident: If the death is accidental, beneficiaries will get the payout only if they claim within a specific time frame after the accident. Most insurers and policies cover the deaths that occur within one year after the accident. Otherwise, they will argue that the accident is not a cause of death and that delay can lead to a denied claim. 

How to Claim Accidental Death Insurance?

Claiming an accidental death and dismemberment insurance process is straightforward. All you have to do is understand what to do along with all the required documents. The documents you may require include the death certificate, copies of medical records, and an autopsy report. You also have to provide some other documents like a police report if the insurance company demands one. 

What are the common reasons an accidental death benefit is denied or delayed? 

Insurance companies are famous for denying and delaying claims no matter what type of policy it is. In the case of the accidental death benefit, they do it by saying that the claim is excluded by the policy. Remember that law never favored exclusions and limitations so it is important to read the policy’s terms and understand them. 

However, here are some reasons why exclusions are interpreted incorrectly by insurers:  

  • Claims of suicide when there is no determination of death’s cause. 
  • Claims that the insured has overdosed when the death’s cause is complicated. 
  • Claims that death is a result of criminal activity with no evidence to prove it. 
  • Claims of intoxication while reports don’t show the policyholder was legally intoxicated. 
  • Claims that the person is not fully disabled or dismemberment within the meaning of the accidental coverage.

Another problem with such claims is that the insurance company will delay the claim in deciding whether it will pay the claim or not. Some decisions can’t be taken on time as the insurer requires documents, conducts interviews, and reviews the evidence of the death. If you notice that there is no progress on your claim decision, hiring an attorney will assist you with your claim. 

What to do if your accidental death and dismemberment insurance claim is denied? 

It seems impossible to prove an exact cause of death especially if the insured already had some illness. It may be due to a pre-existing medical condition, any past event, or an accident involved in a death. Insurers take advantage of that impossibility and deny the claim. If that is the case, you have to consult an accidental death claims attorney to discuss your rights and available options. 

Insurance companies commonly deny the claims by saying that the evidence is inadequate to prove the deceased’s death was accidental. Hiring a good and experienced accidental death and dismemberment claims lawyer will get you out of this situation. He will get witness statements, hire essential experts, do legal research, review your evidence, and give a well-prepared lawsuit against the company if required. 

How can a denial case be handled according to state law? 

If you have bought accidental death insurance from an insurance company without any employer involvement and it gets denied, the state law in the governing jurisdiction will control what law will apply to the denied claim. However, if you want to you can also sue the insurance company. 

On the other hand, if the coverage is bought via an employer, it would be governed by the Employee Retirement Income Security Act of 1974 (ERISA). In addition, before suing the insurer you have to pursue an administrative appeal. In case the appeal fails, your lawsuit will be filed in the US District Court because federal courts have jurisdiction over an employer-sponsored insurance plan. 

At your administrative appeal in a federal or state court, your lawyer has to present the best possible evidence that the cause of death was a fatal accident, due to which the beneficiary is entitled to the full accidental death payout of the policy. 

Summing Up 

Claiming accidental death and dismemberment insurance seems like a very complicated process. Do not let an insurance company take advantage of you and your family. If you think your case is not making prompt progress, consult a lawyer or professional advisor and discuss your situation with him. He will guide you accordingly and give the best possible solution for you and your family.