Accidental Death and Dismemberment Insurance (AD&D Insurance) Denials
If a loved one suffered injury or death in an accident, you may have an accidental death claim. Companies frequently provide accidental death and dismemberment insurance (AD&D insurance) to their employees. While you can buy a personal AD&D policy, this is less common. Unfortunately, AD&D claims are frequently disputed by insurance companies. If you have been denied accidental death benefits, you should consider appealing this decision.
What Is Accidental Death and Dismemberment Insurance?
AD&D policies pay benefits when someone is killed or injured in an accident. Unlike life insurance or long term disability plans, accidental death claims only cover accidents. In other words, if the death or disability is caused by illness, old age, or self-harm, you are not eligible for AD&D benefits.
While many AD&D insurance claims deal with the death of a loved one, you may also be eligible for benefits if you lose a limb, eye, or are permanently and totally disabled. Accidental disability benefits are frequently paid at the same rate as death benefits.
However, before you file an accidental death claim or appeal, you must understand the terms and conditions of your policy. You should request a copy of your AD&D insurance plan’s summary plan description (SPD) and plan document. The SPD and plan document will detail:
- Benefit amounts,
- Eligibility for benefits (and exceptions),
- Claim and appeal procedures, and
- Filing deadlines.
Without this information, it is impossible to file a successful accidental death claim. You should also prepare for a fight with the insurance company. Get complete copies of the medical records, death certificate, autopsy report, and other relevant information. You should also consider speaking with an experienced AD&D insurance lawyer.
Common Reasons for an AD&D Insurance Denial
Accidental Death and Dismemberment policies are notoriously complicated, especially without the help of an experienced AD&D insurance lawyer. Compared to life insurance and long term disability policies, they are relatively inexpensive to buy. For this reason, AD&D plans typically include numerous loopholes and exceptions.
Due to this intentional complexity, many accidental death claims are denied. Common reasons include:
- A pre-existing condition or illness contributed to the death or disability,
- Medical treatment (including medication) caused the death or disability,
- The injury or death was unwitnessed,
- Evidence of substance use or abuse,
- The death did not occur within a specific time period, or
- The accident (allegedly) falls within one of the policy’s many exclusions and exceptions.
Insurance companies frequently deny valid AD&D claims. If you are denied, contact an AD&D insurance lawyer immediately for an evaluation. He may be able to help you successfully appeal the insurance company’s decision.
Filing an AD&D Appeal
If you have an employer-funded AD&D insurance plan, the Employee Retirement Insurance Security Act (ERISA) applies. Because ERISA is a federal law, it preempts state laws and you must follow specific appeal procedures before filing a lawsuit. This includes a required administrative appeal with the plan’s administrator. If the insurance company denies your administrative appeal, you may then file a federal lawsuit. Depending on your AD&D plan, different filing deadlines may apply. Make sure you understand the exact appeal procedures of your plan — non-compliance may result in a dismissal of your accidental death claim.
ERISA accidental death claim appeals are more technical and complicated than their state law counterparts. If you are denied company-provided AD&D benefits, consult with an attorney before filing an appeal. A lawyer can help you understand your rights, guide you through the appeal process, and ensure that you properly develop your claim and support it by evidence.
If you have a personal AD&D policy (possibly included as a rider to your personal life insurance policy), state laws apply. In these non-ERISA appeals, you may immediately file a lawsuit with the court, demand a jury trial, and may be eligible for punitive damages if the insurance company denied your claim in bad faith. However, strict filing deadlines may apply in your case. If you do not file a lawsuit before this filing deadline or statute of limitations, your claim will be dismissed.
Contact an AD&D insurance lawyer
Due to the complexities of an accidental death claim, you should retain legal counsel before filing a claim or appeal. With over 20 years of experience, J. Price McNamara provides select AD&D insurance claimants with personalized representation.