Many life policies and employer benefit plans include accidental death and dismemberment coverage, often called AD&D. Insurers deny these claims frequently, and the reasons are not always obvious from the denial letter.
Common grounds for denial
The insurer says the death was not an "accident" as the policy defines the term.
An exclusion applies, such as for intoxication, certain activities, or a pre-existing condition that contributed to the death.
The insurer argues the death resulted from illness rather than an accidental injury.
The policy was not in force or the coverage amount is disputed.
Why wording matters
Policies define accidental death in their own language, and courts read that language closely. Exclusions are generally interpreted against the insurer when they are ambiguous, but the insurer may still have strong arguments depending on the facts. Who has the burden on which issue can also depend on the policy and the type of plan.
Employer plans can be different
If the coverage came through an employer, federal law known as ERISA may govern the claim. That can change the appeal process, deadlines, and the kind of court review available, so do not skip the plan's internal appeal steps.
What to do next
Request the full claim file and the policy or plan documents in writing, keep the death certificate and any police or medical examiner reports, and calendar every appeal deadline listed in the denial letter.
An accidental death denial often rests on a narrow reading of one word or one exclusion. A careful look at the policy language and the evidence can change how strong the denial really is.
Davila Cobos Law Firm, PLLC represents clients in San Antonio and Laredo. Learn more about our life insurance denial attorney services, or contact the firm to discuss your situation.
This article is general information, not legal advice, and reading it does not create an attorney-client relationship. Every situation is different, so talk to a Texas attorney about yours.
