Accidental Death and Dismemberment Insurance Lawyers

It is difficult to recover from the loss of a beloved family member, but when a loved one dies under circumstances that are sudden and unforeseen, the pain can be even greater. Too often, valid death and dismemberment claims are denied because of avoidable problems with the claim submission.

Help for Families Facing Denied or Confusing AD&D Insurance Claims

If you have experienced such a loss, it is important to ascertain whether the deceased was covered under an accidental death and dismemberment (AD&D) insurance policy.

Accidental death and dismemberment insurance can be very confusing. And AD&D is different from life insurance. We’re here to help. No matter the situation, you deserve to have someone fighting for you to be sure that as a survivor you receive adequate financial support for your loss.

What Is Accidental Death and Dismemberment Insurance?

Accidental death and dismemberment insurance differs from life insurance in that it pays out to a beneficiary when the policyholder passes away due to an accident, such as a car crash, a fall, or drowning. An AD&D policy does not provide benefits if the policyholder passes away due to an illness or other natural causes unless triggered by exposure or trauma.

There needs to be an intervening accident, although the meaning of what constitutes an “accident” is rarely defined in insurance policies. Circumstances where coverage is unavailable would include sudden death due to a heart attack or stroke or even, in most situations, death that results from an illness such as COVID.

However, even those situations may be covered if there is a concurrent event that was itself the cause of death. Although the law on this point varies in different jurisdictions, an otherwise non-fatal heart attack may cause someone to lose control of a car and crash. If the injuries from the collision rather than the heart attack are the cause of death, AD&D coverage may be available.

The following are other circumstances where accidental death or dismemberment insurance coverage may be available, even if there is an underlying illness:

• Situations where the illness might cause a drowning in a body of water or even a bathtub
• Losses due to the stresses of scuba diving or mountain climbing
• Situations where a non-fatal accident can trigger a chain of events resulting in death
• Death caused by a pulmonary embolism following surgery or immobility after an accidental knee injury
• Lengthy air travel resulting in a fatal pulmonary embolism
• Accidental overdose of prescription medication

What Types of Losses Does AD&D Insurance Cover?

AD&D policies typically provide benefits when a covered person dies or suffers a serious injury from an unexpected accident. In addition to accidental death, many policies pay benefits for specific injuries such as loss of a limb, loss of eyesight or hearing, and permanent paralysis caused by an accident. Some policies also cover situations where an accident triggers a chain of medical complications that ultimately leads to death. Because every policy defines coverage differently, the specific benefits available depend on the language of your insurance policy.

For a detailed breakdown of how AD&D coverage works and how courts have interpreted these policies, read our guide to what AD&D insurance covers.

Common AD&D Policy Exclusions

AD&D policies frequently contain exclusions that limit when benefits are payable. Insurance companies rely on these exclusions when denying claims. Common exclusions include deaths caused by illness or natural medical conditions, suicide or intentional self-harm, injuries from participation in illegal activities, and accidents involving drugs or alcohol. Insurers may interpret these exclusions broadly, and disputes over whether an accident truly caused the death are common.

Understanding the exclusions in your specific policy is an important first step when evaluating a denied claim. Our attorneys can help you determine whether the insurer applied the exclusions correctly.

Why AD&D Insurance Claims Get Denied

Disputes Over Whether the Death Was “Accidental”

Many AD&D policies do not clearly define the term “accident.” This allows insurers to argue that a death resulted from illness or natural causes rather than an accidental event, even when the circumstances suggest otherwise.

Pre-existing Medical Conditions

Insurance companies may deny claims when the deceased had an underlying health condition. They may argue that the medical condition caused the death rather than the accident. However, coverage may still apply if the accident set off the chain of events that led to the fatal outcome.

Intoxication or Drug Use Exclusions

Many AD&D policies exclude coverage when alcohol or drugs are involved. Insurers often rely on toxicology reports to support a denial. However, the presence of a substance alone may not justify the denial if it was not the primary cause of death or not relevant to the cause of death such as an intoxicated passenger involved in a car accident.

Insufficient Documentation

Claims may be denied when insurers believe there is not enough evidence to prove that an accident caused the death. Autopsy reports, police and fire department reports, and medical records are often critical to establishing the cause of death and supporting the claim.

If your claim was denied for any of these reasons, it does not mean the decision is final. Our article on how to successfully challenge the denial of an AD&D insurance claim explains the strategies that can help overturn a wrongful denial.

Understanding AD&D Insurance Claim Denials: Mark DeBofksy

How ERISA Affects Your AD&D Claim

If the AD&D policy was provided through an employer, it is likely governed by the federal Employee Retirement Income Security Act (ERISA). This distinction matters because ERISA claims follow strict procedures and tight deadlines. Beneficiaries typically must complete an administrative appeal before they can file a lawsuit, and the appeal stage is often the last chance to submit evidence.

AD&D policies purchased directly from an insurance company are usually governed by state law, which may offer greater flexibility when challenging a denial ,as well as damages unavailable under ERISA. Understanding which set of rules applies is one of the first steps in evaluating how to fight a denied claim.

If you are not sure whether ERISA applies to your AD&D policy, our attorneys can help you determine which rules govern your claim and what steps to take.

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Steps to Take After an AD&D Claim Denial

A denial does not mean the claim is invalid. Taking the right steps promptly can make a significant difference in the outcome.

How to Challenge a Denial of Accidental Death and Dismemberment Insurance Benefits

When sudden deaths occur, there is often an autopsy performed by the local coroner or medical examiner’s office. Under guidance issued by the Centers for Disease Control in a manual entitled “Medical Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death Reporting,” the “manner of death” is to be listed as “accidental” on a death certificate if “there is little or no evidence that the injury or poisoning occurred with intent to harm or cause death.”

In essence, death is deemed “accidental” if the fatal outcome was unintentional. It is difficult to challenge an AD&D denial where the manner of death is listed as natural. Obtaining a copy of the autopsy report in support of a claim for accidental death and dismemberment insurance is critical, as is obtaining any police reports if a law enforcement investigation was performed.

Talk to an AD&D Insurance Attorney

Seattle and Chicago AD&D Insurance Lawyers

While no amount of money can provide sufficient recompense for the sudden and unexpected death of a family member, a denial of accidental death and dismemberment insurance coverage can worsen the pain of the loss. Just because the insurance company says no, though, that does not mean the answer is final.

Consult with an attorney who understands how AD&D policies work and has the experience in successfully challenging a wrongful denial. We have offices in Seattle and Chicago and represent clients nationwide.