Accidental Death and Dismemberment (AD&D) Insurance Claims
Accidental Death And Dismemberment coverage, or “AD&D” coverage for short, is often provided as an employment benefit. Less commonly, individuals purchase these policies directly from the insurer. Compared to some other forms of coverage, AD&D coverage is fairly inexpensive. Insurance companies are generally very smart about pricing their policies. The fact is, the cheaper the insurance, the less likely it is to pay off. So it goes with AD&D — it is cheap insurance that rarely pays off because of the extraordinary amount of “fine print” in these policies.
AD&D policies come in many varieties, but most of the policies we have seen are loaded with “loopholes” in the form of exceptions, exclusions, limitations, and conditions. Most policyholders have no idea what their policy really says. Sometimes even lawyers and judges have a hard time understanding these policies.
At Robinson & Warncke, we guide grieving families through their complex AD&D insurance claims. Our team of experienced insurance attorneys has the skills and knowledge to evaluate your claim and apply the myriad of laws that may apply to it. We also have the compassion and dedication necessary to help you understand your options during a difficult time.
What AD&D Policies Cover
There’s a good chance that you and your loved ones have accidental death and dismemberment policies, either through your employer or as part of your life insurance coverage. Sometimes, you may have a separate, stand-alone AD&D policy, while other times it may be included as a rider.
The heart of every AD&D policy is a lump sum payment when the insured dies in an “accident.” You can think of it as life insurance with a twist — it only pays off if you die “accidentally.”
Many AD&D policies also have benefits that pay even if the insured does not die in an accident. For instance, many policies pay the same amount as the death benefit if an accident causes a career ending injury (“permanent total disability”). Many AD&D policies also pay specific amounts if an accident causes specified physical losses, such as blindness, deafness, inability to speak, loss of limb, or paralysis.
Complications frequently arise when the insured’s death is caused by an accident combined with some underlying pre-existing condition. Other times the insured has what any layperson would call an “accident,” but the insurer says we don’t cover that kind of accident (“exclusions”). These kinds of questions are at the center of many disputes over AD&D coverage.
An Accident by Any Other Name
Few AD&D insurance policies define “accident” the way that ordinary people do. For instance, people don’t dive into water from a pier expecting to hit the bottom and be killed. If such an occurrence came to pass, we would probably call it an “accident.” An AD&D carrier might call it something else. This very case was litigated in our home state of Georgia. The insured beneficiary recovered the death benefit, but only after a long battle.
We have handled two different AD&D cases where the insured died due to an accidental overdose of prescription medication, even though the deceased took the medication according to the doctor’s instructions. In both cases the insurance company disputed that this was an accidental death, attempting to broaden a policy exclusion for losses caused by “medical or surgical treatment.” In both cases we recovered the full benefit for the surviving family.
Most people would think that a death caused by a car wreck would be covered as “accidental.” However, if an insurance company doctor “determines” that the wreck itself was caused by the driver having suffered a heart attack, the claim might be denied due to a “pre-existing” heart condition. Believe it or not, there are dozens of such cases reported in law books.
Other Reasons Insurance Companies May Deny AD&D Claims
Insurance companies may also deny an AD&D insurance claim if there is evidence suggesting that the death was due to:
- Known risks associated with a medical procedure or treatment
- Occupational accidents or diseases
- Substance abuse or intoxication
As mentioned above, AD&D policies include complex exclusions, claims procedures, and deadlines. A single mistake can result in an AD&D insurance denial. However, do not assume that the adjuster or insurance company is properly interpreting the terms and conditions of the policy. Instead, consult with a knowledgeable insurance lawyer who can interpret the plan documents and properly apply them to your claims.
Another common issue in an AD&D insurance claim is a death that was unwitnessed and difficult to explain. In these cases, the insurance company rarely gives the deceased and their loved ones a benefit of a doubt. Proving the cause and manner of death is always a challenge when there are no witnesses. If the cause of death is not immediately obvious, making that determination can become a much more rigorous scientific exercise.
It takes an experienced Accidental Death and Dismemberment Insurance lawyer to analyze the policy and to determine whether the insurance company is interpreting it properly. A successful outcome also depends upon having an attorney who is willing to hire reputable scientific experts to prove how the insured died, and that it is a covered loss.
If ERISA Applies Then You Need AD&D Insurance Attorneys
In simple terms, where your employer provides you AD&D coverage, the federal law known as ERISA will control your claim. The distinction is often important when a claim is denied. Compared to a typical contract or insurance claim, ERISA claims are governed by a complex series of rules. These rules impact the appeal process, your legal rights, and the filing deadlines.
At Robinson & Warncke, we take a hands-on approach to every AD&D insurance claim we handle. This means that we:
- Spend time with our clients, listening to their stories and answering their questions
- Carefully review insurance company files and policy documents
- Investigating our clients’ claims and identifying gaps in the evidence
- Compile important evidence, such as medical records, police and coroner’s reports, and toxicology records
- Consult physicians, accident reconstruction experts, engineers, and other experts that can help clarify issues in the claim, especially when the cause of death is disputed or unclear
- File timely appeals with either the insurance company, federal, or state courts (depending on the nature of the AD&D insurance denial)
- Negotiate with the insurance company
- Educate our clients about their comprehensive legal options and suggest strategies that are practical, cost-effective, and in their best interests
An experienced attorney knows the differences and knows how to handle both kinds of cases. Especially in the case of ERISA claims, time is of the essence. Sometimes we have as little as 60 days to submit proof to overturn a claim denial. Given these short deadlines, it is crucial you call an experienced lawyer as soon as you find out your claim has been denied.
Get Experienced, Effective Help With Your AD&D Insurance Claim
The firm of Robinson, & Warncke has more than 20 years experience helping people in and around Atlanta, throughout Georgia, and nationally to recover the life and accident insurance benefits they have paid to obtain. If you have been denied benefits under your Accidental Death and Dismemberment policy, or under a disability or life insurance policy, we can help. We can also analyze whether the insurer’s actions warrant a bad faith claim that would offer recovery over and above the policy benefits.
Call us today for a free analysis of your case. We have a proven record of success on the cases we accept.