Accidental Death Claim Help
It’s very difficult to get an accidental death claim paid. Thorough investigation and claim preparation are the keys to getting an insurer to say ‘yes’. If you need help with an accidental death claim, I’m the person you’re looking for.
I’m Steve C. Burgess. I’ve represented beneficiaries of accidental death claims for over 30 years.
During my career I’ve fought every major life insurer, and many little ones, over accidental death claim challenges such as whether a drowning was accidental or suicide, how a firearm can discharge accidentally, why choking to death is independent of preexisting medical conditions, how Tesla’s self-driving feature makes blood alcohol irrelevant, and why drug-to-drug interaction cannot cause a claim to be denied under policy exclusions.
I’ve fought and won some of the toughest accidental death claim approvals in the US.
To file a new claim that an insurer will approve, or to fight a denied claim, contact me.
There are common procedures that claim examiners follow when evaluating an accidental death claim. They tend to stay within these procedures even though there are always exceptions and unique circumstances to each claim. Too much gets ignored by treating claims this way.
During formal litigation I’ve testified more than 200 times regarding the fair and unfair practices of insurers leading to death claim decisions. I’ve used my experience in underwriting and issuing more than 2000 life insurance policies to investigate the acts of insurers and pinpoint their procedural deficiencies.
I founded and am acting President of The Center for Life Insurance Disputes. And, proudly, I’ve helped put more than $250 million in the hands of the survivors and loved ones who needed help with an accidental death claim.
Here you’ll get quality insight and straight-forward answers to common claim topics and questions including:
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How to prepare a new claim so it pays quickly.
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How to get medical records.
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What to expect during a claim investigation.
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What are Policy Exclusions.
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The challenges of drug overdose deaths.
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Ways to fight a denied claim.
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Additional considerations.
Accidental Death Claim Help
There’s no tougher insurance claim to get paid than an accidental death claim.
To get a claim approved, first the death or dismemberment has to meet the policy’s definition of accident. Then, as every policy has a list of Exclusions which allows an insurer to deny any claim, the death or dismemberment has to occur free of any exclusions. The Exclusions are written right into the policy and they cover the more common circumstances that lend to accidental deaths.
If a death occurs without a witness or a way to confirm an accident was the sole cause, the claim will likely be dismissed. And finally, the claim benefit may decrease at certain ages, and many policies require that a claim has to be filed in a certain time-period after the death.
For dismemberment claims, the accident has to cause a specific damage – not just the loss of use – before a claim will pay.
Then there’s the insurers’ motivation to not payout Accidental Death & Dismemberment (1) claims. Just consider the financial aspect of a policy to the insurance company. The premiums are extremely low for the benefit offered. It’s common to see monthly premiums of only $2.00 or $3.00 that cover a $100,000.00 benefit. An insurer can’t stay solvent by paying out $100,000.00 when they’re only taking in $36.00 a year of premium. They can’t.
What this all comes down to is when it comes to getting an accidental death claim paid it’s the claimant versus the insurance company. Here we’ll explore in great detail how to help the claimant win.
Accidental Death & Dismemberment Insurance Claims
An Accidental Death & Dismemberment insurance (2) policy pays a lump sum of money if the insured person dies from an accident or loses the use of a limb or significant bodily function such as sight or hearing. Most claims are governed by the State’s regulations the policy was issued in (3).
Accidental Death & Dismemberment insurance may also be referred to as AD&D or Accidental Death insurance and can either be a supplement to a life insurance policy (4) or a policy of its own. Throughout this website the term accidental death insurance will be used interchangeably.
The purpose of this guidance is to inform and educate the public on Accidental Death claims so that, in the event of having a claim, he or she knows what to expect from the claim examination process, what the challenges are to getting a claim paid, how to overcome those challenges so the claim is not denied, how to properly prepare an accidental death claim so it pays, and what resources exist to aide claimants at any point in the claim process.
How to Prepare a New Claim So it Pays Quickly
When preparing a claim for an accidental death or dismemberment, think details. The insurer’s Claim form gives limited space to share details that may be important to your claim. It’s important to get any information that supports your claim into the hands of the insurer.
Take the initiative of gathering as much detail as possible. This means getting medical records, incident reports, corroborating statements and, of course, a final death certificate.
Along with the Claim form, send a cover letter explaining how the policy benefit was triggered (i.e. death by accident, loss of bodily function, and so on), why none of the Exclusions apply, and how to contact you directly. Doing this will help the claim examiner understand the facts of the covered loss and assure that they don’t overlook information that’s important to the evaluation of your claim.
How to Get Medical Records
If a claim is for dismemberment the insured will obtain or release their own medical records. That’s easy. If the claim is for death a survivor has to sign a records release. Because a person’s medical records are protected under federal laws (cite) this isn’t always a simple thing to do.
In most instances the only person who has authority to sign a medical record release for a deceased is their surviving spouse. If the beneficiary to the claim is the surviving spouse, there usually isn’t an obstacle. The surviving spouse signs an authorization for the insurer to obtain medical records, they submit this to the medical facility with a death certificate, and records are released.
But when the beneficiary is not a surviving spouse things get much more difficult. Medical facilities, especially large hospitals, follow Privacy rules to the “t”. They will reject a record request that isn’t properly executed. For example, when a father leaves a death benefit to his daughter. The daughter, under federal law, isn’t an authorized signee and the hospital will reject the request.
So how can a non-spouse beneficiary get medical records released for the claim investigator to do their investigation and pay the claim? It may require a limited Court Order or having to open an estate. Opening an estate isn’t always possible. And even getting a limited Court Order may not satisfy the medical facility – especially if it’s a designated Military Treatment Facility. These situations get complicated. Therefore, the best advice is to get help from an expert.
What to Expect During a Claim Investigation
I tell jurors and judges all the time, ‘if an insurance company wanted to pay a death claim they wouldn’t do an investigation’. The claim investigation is an effort by the insurer to get out of paying a claim. That’s what they’ll be doing and why it’s important for a claimant to prepare a thorough claim filing. Once a claim is submitted there will be a period of investigation by the insurer.
For accidental death and dismemberment claim investigations the attention will be on the policy exclusions. The examiner will request documents related to the death. This can include medical records, sheriff reports, toxicology results, and others. As it can take quite a while to obtain certain records, it’s best if the claimant can obtain them him or herself.
What they do with the information is to compare details against the many exclusions (see Policy Exclusions discussion below).
During the investigation there will be very little communication shared with the claimant. In most cases the insurer will send a form letter every 30 days that says they’re still working on the claim. In fact, once all the records they want are in-hand, the claim file will move from the examiner to a doctor, to a lawyer and back to the examiner. Ultimately, either a claim check will be mailed or a letter explaining why the claim was denied.
What are Policy Exclusions for Accidental Death Insurance
Exclusions to an AD&D policy are specific circumstances that dismiss an insurer from having to pay a claim even when the loss was accidental. Every accidental death and dismemberment policy has exclusions, but each may vary from one policy to another.
Here is an example of Policy Exclusions taken directly from a policy issued by a major insurer:
In no event will the AD&D benefit be paid where the loss is caused directly or indirectly by, results from, or there is contribution from, any of the following:
- Self-inflicted injury or self-destruction, whether sane or insane.
- Suicide or attempted suicide, whether sane or insane.
- Participation in or attempt to commit a crime, assault, or felony.
- Bodily or mental infirmity, illness or disease.
- The use of alcohol, drugs, medications, poisons, gases, fumes or other substances taken, absorbed, inhaled, ingested or injected, unless taken upon the advice of a licensed physician in the verifiable prescribed manner and dosage.
- Motor vehicle collision or accident where the employee is the operator of the motor vehicle and the employee’s blood alcohol level meets or exceeds the level at which intoxication is defined in the state where the collision or accident occurred, regardless of the outcome of any legal proceedings connected thereto.
- Infection, other than infection occurring simultaneously with, and as a direct result of, the accidental injury.
- Medical or surgical treatment or diagnostic procedures or any resulting complications.
- Travel in or descent from any aircraft, except as a fare-paying passenger on a regularly scheduled commercial flight on a licensed passenger aircraft carrier, or except for an employee who is a pilot, crew member or passenger on an aircraft owned, operated or leased by a state or local government employer and being used for business of that employer.
- War or any act of war, whether declared or undeclared.
As is obvious from this example, insurers spend a great deal of energy on creating policy exclusions. But with deaths or dismemberment, details matter. In other words, while at first glance it might seem like an exclusion does apply, but only after all facts have been uncovered it turns out the exclusion doesn’t apply. As an example, when a person dies during surgery. On the surface it might appear the claim is excluded, but after investigation it’s discovered the hospital failed to meet minimum treatment standards.
An insurer’s claim investigation will only go as far as it needs to so the claim can be denied. Instead, every effort needs to be made by a professional to discover why a claim has to be paid.
The Challenges of Drug Overdose Deaths
Very few people intentionally take their own lives by overdosing. Instead, most people accidentally overdose.
Especially in the United States, death by drug overdose is quite common. As a nation, the use of prescription of drugs is tremendous. The power of pain killers, mood stabilizers and anti-psychotic pharmaceuticals is underappreciated. Likewise, controlled substances like cocaine and methamphetamine, and the potency of such, make them deadly to many unsuspecting people.
This raises the challenge with accidental death insurance; will a claim pay for an accidental overdose? From experience I can say “yes”. But, unless properly investigated before the claim is filed, the claim will probably be denied and then have to be appealed. The insurer won’t do a thorough enough investigation to unravel a drug overdose death. They’ll see the Cause of Death on a certificate and deny the claim. Then, a thorough investigation and appeal have to occur.
In order to get these claims paid one has to look at the substance(s) in the toxicology report and the circumstances around the time of death. There are links that can be made between drug effects, a person’s use of a drug, drug-to-drug interactions and unintentional consequences.
Ways to Fight a Denied Claim
When an Accidental Death & Dismemberment claim is denied the claimant will receive a letter explaining why it was denied and some standard language about rights and Consumer Protection agencies. But, in reality, if a denied claim is going to be fought and won the beneficiary will need to engage experts who know how to fight claim denials.
There are several avenues of advocacy to consider for fighting a denied claim. Each will vary in cost, knowledge, timing, availability to geographic area and experience with accidental death insurance claims.
Independent claim experts. These are experts who investigate accidental death insurance claim denials and fight the insurer directly on behalf of the claimant. If they’re effective and win, the claim will be paid at a low cost for their services. If the insurer refutes the appeal a lawsuit can then take place.
Small claims court. Depending on the dollar limits for any particular county, small claims court can be used for claim recovery. Many Small Claims Courts have a dollar limit of $12,000.00 to $15,000.00. Therefore, if the denied claim is under these amounts, a judge will hear the claimants’ argument for the claim and may order the insurance company to pay.
Pro Bono legal assistance. Most County Bar Associations offer some degree of pro bono support to those who cannot afford paid legal representation. However, the person(s) available may not have any experience in the specialization of accidental death and dismemberment insurance.
Insurance lawyers. An experienced accidental death and dismemberment insurance lawyer can be found in or near most major metropolitan areas. If a lawyer wants to take a claim case, they’ll usually do so without any retainer required by the client. However, legal fees for AD&D insurance claims are typically 40% of any money recovered.
For a more detailed discussion on how to fight a denied accidental death and dismemberment insurance claim go to: (Fight a Claim Denial).
Other Considerations
Working through the grief after the loss of a loved one takes a tremendous amount of energy. The pain, sleepless nights, debilitating sadness and a whole lot of other emotional and physical challenges all take a toll and need time to work out. While it may be therapeutic to focus one’s energy on a project, fighting an insurance company isn’t one I recommend. Insurers are well prepared to fight back. Instead, use an expert who can fight for your claim. Whether a lawyer, an advocate or another, let someone else win your claim so you can use your energy to heal.
By: Stephen C. Burgess, Insurance Claims Expert, President of The Center for Life Insurance Disputes.
The information on this website is intended to help beneficiaries get accidental death claims paid through answers, education and assistance. New claims and Denied claims.
Also visit Critical Illness Claim Help
(1) https://www.investopedia.com/terms/a/accidental-death-benefit.asp
(2) https://content.naic.org/sites/default/files/model-law-900.pdf