Sickness, Illness, and Natural Causes Exclusion

Nationwide Representation for Accidental Death and Dismemberment Insurance Sickness, Illness, and Natural Causes Exclusion Denials

How to Beat Sickness, Illness, and Natural Causes Exclusion Denials in Accidental Death and Dismemberment Insurance Claims

On this page, former insurance company attorney J. Price Mc Namara explains, step-by-step, how to fight and win sickness, illness, and natural causes exclusion denials, with real examples from his own clients’ past cases:

The sickness, illness, and natural causes exclusion is one of the most common reasons insurance companies give for denying accidental death and dismemberment claim denials.

The clients we represent typically have claim denials involving one of three main ways that this exclusion is written. They may seem similar at first, but are actually very different conceptually.

1. Exclusions requiring only that sickness or illness caused or contributed to the Accident Which resulted in the insured’s death, even if the sickness or illness alone would not have resulted in Death
2. Exclusions that apply only if sickness or illness caused or contributed to the Death Itself, even if it did cause the Accident
3. Exclusions that apply if sickness or illness contributed to Either The accident Or The death

I find these cases to be the most complex, but often present the greatest opportunity to win for the client if properly investigated and executed.

As you read on, keep in mind that most policies are written in terms that the death the “loss” or “injury” as distinguished from the “accident.” the policy language can be tricky.

Also, these exclusions may refer to any combination of the words sickness, illness, disease, bodily or mental infirmity, or natural causes contributing to an accident or death. For simplicity, we’ll refer to them all as “sickness or illness” exclusions.

Like other accidental death insurance cases, the underlying accidents involved in these denials tend to be falls, drownings, atv or four-wheeler accidents, motor vehicle accidents, motorcycle accidents, and bicycle accidents, and boating accidents.

But these cases also involve more complicated matters, such as exposure to the elements (freezing) resulting in death, pulmonary embolism deaths days after a minor injury, suffocation accidents, and accidental deaths that occur during routine medical procedures.

One important advantage to the claimant, is that the burden of proving that the facts support a denial based on Any Exclusion is on the insurance company, not the claimant. The courts say it this way: “[a]s a matter of general insurance law, the insured has the burden of proving that a benefit is covered, while the insurer has the burden of proving that an exclusion applies.” Estate of thompson v. sun life assur. Co. of canada, 603 f. supp. 2d 898, 908–09 (n.d. tex. 2008)

Placing the burden of proving an exclusion from coverage on the insurer is fair, equitable and makes perfect sense. Otherwise, in this case, the insured would be required to prove a negative: that illness Did not Cause or contribute to the accident or loss. It makes better sense for the insurer to bear the burden of proving a positive – not just that the insured had some illness, but also that illness Did Cause or contribute to this accident or loss. Placing the burden on the insurer helps greatly when the evidence is inconclusive.

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Appealing a Sickness, Illness, and Natural Causes Exclusion Denial for Best Results

When you read your denial letter blaming this exclusion, it will seem far-fetched and nonsensical. It may or may not be, depending on the factual evidence, the medical evidence, and the exact wording of the policy exclusion. All three are equally important.

Our clients in these cases always come to find out that the precise wording of the policy exclusions involved, and how the courts interpret them, are very complicated.

So while the denial letter may seem ridiculous, the appeal must be well investigated and well supported with true evidence. Just arguing that the denial is wrong or unfair won’t help. The appeal must also be accomplished very quickly before the appeal deadline (usually 60 days after a denial letter) or the insurer wins by default.

Take it from a former insurance company attorney whose mission is now to help people overturn denials. If you get a denial letter citing this exclusion, don’t wait. The insurance company is extremely educated on making these denials stick. They are often wrong. But in my opinion, you should not appeal your case without the help of an attorney experienced in this area of practice to get it right.

This is critical: the insurance company’s denial will be supported by opinions from physicians and other expert witnesses that the insurance company hires and pays. It is almost always a mistake to appeal such a denial without retaining similar expert witnesses of your own to

Issue opinion reports disputing them and the denial rationale to support your appeal. You must explain to Your Experts exactly how courts interpret the particular exclusion at issue. Many claimants and attorneys will skip this step, which can cause the loss of a case that could have been won.

Follow the steps below for best chances of winning an appeal.

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Understand Your Denial Letter and The Specific Wording of The Intoxication Exclusion in Your Policy Is Critical

Sickness, illness, and natural causes exclusions are written very differently from policy to policy, and in my opinion are the most complex. Very slight differences in their wording are interpreted very differently by the courts, and can make or break a case. Understanding the exact language of the policy exclusion, and how courts interpret it, form the foundation for everything else in your appeal. It drives understanding where the insurer’s reasoning may be flawed, where its evidence may be weak, what factual evidence you need to gather, what medical records you need, and what expert witnesses you need to hire.

You also need to thoroughly understand the evidence and reasons that the insurance company claims that denial is supported. Sometimes you can see right away that the insurer is interpreting the exclusion contrary to court interpretations. Other times, their interpretation of the exclusion is right, but their evidence is weak.

Take note of all evidence they say supports the denial, and whether they relied on the opinion of any expert witnesses. This will further inform you on what experts you may need to hire for the appeal.

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Understand the Three Major Types of Sickness, Illness, or Natural Causes Exclusion

The sickness, illness, and natural causes exclusions found in most accidental death and dismemberment insurance policies fall into three major categories. Which category yours falls into will inform you what the insurance company must prove, factually, to support its denial.

1. Exclusions Requiring only That Sickness or Illness Caused or Contributed to The Accident which Resulted in The Insured’s Death, Even if The Sickness or Illness Alone Would Not Have Resulted in Death

Under this type of exclusion, the burden of proof is on the insurance company to prove merely that the sickness or illness caused the accident. They do not have to prove that the sickness or illness would have caused the death itself.

Example fact pattern resulting in exclusion under this variety: Suppose a victim of epilepsy has had periodic seizures for years. Their seizures are always minor, and medically never expected to cause death. But one day he has the misfortune of suffering a minor seizure while walking near a shallow ditch with water 12 inches deep. He falls into the ditch with his head submerged long enough to drown.

Even if all medical experts agree that the seizure would not have caused him to die, except for the misfortune of being near a ditch and drowning, coverage would be excluded under this category of exclusion. The sickness or illness only needs to cause the accident to bar coverage. Independently causing the death is not required.

But claim denials under this type of exclusion can still be overturned by demonstrating that the evidence cannot carry the insurer’s burden of proof that sickness or illness caused the accident. A good example would be if the above epilepsy victim did not know how to swim, and he was found drowned in the deep end of a swimming pool. If nobody witnessed the accident, it would be hard to conclude that his epilepsy condition caused him to fall into the pool, rather than a simple stumble unrelated to any seizure, coupled with his inability to swim. So it would be hard for an insurer to maintain a claim denial if properly contested on appeal.

2. Exclusions that Apply only If Sickness or Illness Would Have Caused or Contributed to The Death itself, Even if It Did Cause the Accident

Under this type of exclusion, the burden of proof is on the insurance company to prove that the sickness or illness caused the Death Itself. proving that sickness or illness caused the Accident Is not sufficient standing alone.

The following reported case examples illustrate how these types of exclusions are worded, and how courts interpret them:

In the texas case of National life & accident insurance co. v. franklin, 506 s.w.2d 765 (tex.app.1974), the insured, who had a history of epileptic seizures, was found dead in a bathtub. The insurance policy at issue covered losses resulting “directly and independently of all other causes, from bodily injuries effected solely through external, violent and accidental means,” and contained an exclusionary clause prohibiting payment for losses that “result from or [are] contributed to by any disease or mental infirmity.” Id. At 766. the court held that, even if it was determined that the insured’s epilepsy caused him to lose consciousness and fall into the bathtub, it did not cause the death. Id. At 767. the court explained, “[t]he epilepsy was merely a cause of a cause And was therefore too remote to bar recovery.” Id. (emphasis added).

In Kellogg v. metropolitan life ins. co., 549 f.3d 818 (10th cir.2008), the court addressed a case where an insured suffered a seizure which caused a car accident. The court found that the insured’s death was caused by a skull fracture resulting from a car accident, not by the seizure that caused the car accident. Id. At 832. the court stated, “[t]he plan does not contain an exclusion for losses due to accidents that were caused by physical illness, but rather excludes only losses caused by physical illness.” Id. The court concluded, “[t]he fact that the policy at issue here excludes losses that were caused or contributed to by physical illness does not change

This analysis. A reasonable policyholder would understand this language to refer to causes contributing to the death, not to the accident.” Id. “[c]ourts have long rejected attempts to preclude recovery on the basis that the accident would not have happened but for the insured’s illness.” Id. At 831. the court concluded that since the insured’s death resulted from a skull fracture as a result of the car accident, and not the underlying sickness, the policy exclusion did not apply. Id.

Back to our example fact pattern: Our drowning epilepsy victim in the above example of drowning in the shallow ditch above would not be excluded from coverage under this type of exclusion, because the medical experts agreed that the seizure would not have itself been fatal, even though it did cause the accident.

Example from one of our clients’ cases involving this type of exclusion as applied to a Prudential life insurance company denial that it reversed after our appeal:

The Facts

Our widowed texas client’s husband drowned in a hotel swimming pool while swimming laps for exercise. Although he was a strong swimmer, the sole witness said that he was thrashing around in shallow water when he went under. The witness was too feeble to pull him out of the pool, so she ran for help. In the meantime he unfortunately drowned.

The autopsy report concluded that the victim had a heart attack and drowned, but didn’t specify whether the heart attack would have itself been fatal if he had not drowned.

The Denial and Exclusion

Prudential life insurance company denied the claim for accidental death benefits citing the following exclusion:

This coverage pays benefits for accidental loss [death] Which results from an accident…

Benefits for accidental loss are payable only if all of these conditions are met:

• The person sustains an accidental bodily injury [lungs filled with water]…

• The loss [death] Results directly from that injury and from no other cause.

Losses not covered:

A loss is not covered if it [the loss, death] Results from any of these: …

• Sickness, Whether the Loss Results Directly or Indirectly from The Sickness.

The Appeal

We reviewed all evidence in the claim file, secured the deceased husband’s medical records, and hired a highly-credentialed physician in the electrophysiology sub-specialty of cardiology medicine as our expert. He reviewed all available evidence and gained a full understanding of

Our exclusion. In his opinion, the likely cardiac event that precipitated the accidental drowning would not have itself been fatal, were it not for the drowning.

I provide some detail of our expert’s opinion here to show that the medical issues in these cases can be deep and complicated, and need to be reviewed by someone trained in the medical specially at issue in the case. Not just any physician will qualify or have the specialized knowledge to be convincing. He said:

“In some ways, i agree with the opinion by the insurance company’s physician that [the insured] more likely than not suffered a medical event that triggered his drowning….But, assuming a medical event did occur, based on [his] past medical history, and the description of the sudden struggle in the water in this man who was a reported good swimmer, who did not suffer an acute myocardial infarction, and who had a normal glucose of 102 when paramedics arrived at the scene, statistically the most likely preceding event would have been an episode of an arrhythmia.

Two different arrhythmic scenarios are most likely, although neither one would be expected to be initially lethal on dry land. Given [his] cardiac status of coronary disease, a known prior myocardial infarction with inferior scar, a history of premature ventricular beats, and history of one short episode of a slow nonsustained ventricular tachycardia at 145bpm, one scenario is that he may have suffered an episode of ventricular tachycardia. If ventricular tachycardia did occur, it would more likely than not have been a fairly “stable” arrhythmia with a probable chance of survival or successful resuscitation, save the fact that it occurred in a pool, causing him to struggle and initiate the drowning which caused his death. It is highly unlikely that his initial arrhythmia in the pool was ventricular fibrillation (sudden cardiac death), as [he] was able to struggle for a while and still had a pulse and some spontaneous breaths when ems arrived minutes later, despite having an airway full of water. This would not be expected in a person with primary ventricular fibrillation.

Another potential arrhythmic trigger for the struggle in the pool could have been an episode of paroxysmal atrial fibrillation. He had multiple risks for atrial fibrillation including his coronary artery disease, prior myocardial infarction, hypertension, obesity, and history of moderate alcohol consumption. An episode of atrial fibrillation may have decompensated him just enough to swallow water and initiate the entire drowning sequelae. In that case, an arrhythmia of atrial fibrillation would not have been lethal on dry land.

So in conclusion, i would surmise that a medical condition was not likely the direct cause of [his] death, but could have decompensated him enough to precipitate his drowning. Had his presumed medical event occurred on land, his symptoms would have likely been limited to chest pain, shortness of breath, near syncope, or syncope. Even in the worst-case scenario that [his] presumed medical event was an arrhythmia to require resuscitation, had the event occurred outside

Of the water, resuscitation would have been initiated earlier, he would not have had and airway and lungs full of water, and efforts at resuscitation would have been more successful. Only because the event occurred in the pool, [he] perished from drowning.”

The Outcome

Prudential reversed its denial and awarded our client all benefits.

Key takeaway: without fully understanding the exclusion and how courts interpret it, hiring a top-notch expert to support our case, gathering the important evidence, and timely presenting all of this on appeal, we would not have likely won the case.

Thus, understanding the reasons the insurer gives in the denial letter, the precise wording of the sickness or illness exclusion in the policy and how courts interpret it, is the critical first step to properly analyze the claim and the insurance company’s denial. It also informs what evidence and expert opinions you may need for the appeal.

We’ll now examine the third type of sickness and illness exclusion.

3. Exclusions that Apply if Sickness or Illness Caused or Contributed to Either The Accident Or the Death

This type of exclusion poses the toughest challenge for claimants.

Example from one of our successful clients’ appeal of Securian Life Insurance company’s denial under this third type of exclusion illustrating how to fight such a denial:

Our Ohio clients were the two children and fiancé of the insured who died in a car crash while insured under an ERISA-governed accidental death and dismemberment policy. They were his beneficiaries.

The Exclusion

Securian’s exclusion stated:

In no event will we pay the accidental death or dismemberment benefit where your Accident, injury, loss, death or dismemberment Is caused directly or indirectly by, results in whole or in part from or during, or there is contribution from, any of the following:

(4) a bodily or mental infirmity, illness or disease;

Simply put, this exclusion only requires that the insurer prove that sickness or illness cause or contribute to Either The accident Or The death (loss) to bar coverage.

The Facts the Insurer Had for The Initial Denial

The accident was unwitnessed. The insured’s truck left the road and struck a large tree crushing its engine and intruding far into the front seat compartment. He died at the scene. The insured had a minor heart condition according to the autopsy, which also said that the heart condition contributed to the insured’s death.

Additionally, based on only these facts, securian had retained an expert whose opinion stated that a heart condition caused the accident itself, and the death, that the heart condition likely resulted in death even before the insured’s truck struck the tree, and that the accident would not have been fatal but for the heart condition.

Covering all its bases, securian denied the claim on the grounds that sickness or illness either caused or contributed to either the accident, the death itself, or both.

The Appeal

Our own investigation revealed the following: the accident took place on a very hot evening after the insured had mowed his uncle’s lawn after rising early and completing his regular workday. His uncle had covid at the time, so the insured refused to come inside his home to cool off, and likewise refused his offer of water. He got into his pickup truck and headed home. The fatal accident happened on his drive home.

We questioned whether the insured had become dizzy, faint, or passed out simply due to becoming overheated from the exertion of mowing a lawn and refusing water, having nothing to do with any heart condition. Or did he fall asleep, or get distracted by texting, or something else? We’ll never know. But there seemed to be no reason to assume that a heart condition caused the accident over any other possible cause just because some heart condition merely existed.

Applicable case law says that very clearly, and the insurer has the burden of proof to support an exclusion:

Our favorite court quote about the absurdity of how insurance companies sometimes treat sickness or illness exclusions says it all:

See hall v. metro. Life ins. co., 259 fed. appx. 589, 591 (4th cir.2007) (allowing insurance companies to presume a medical condition caused an accident over any other cause just because a medical condition existed would only pay benefits under facts like “a truck dropping from the skies, striking squarely and killing instantly a perfectly fit human specimen clutching a just-issued physician’s clean bill of health.”)

Interviewing those closest to the insured who interact with him regularly, we learned that they had never observed, or heard the insured complain of, being faint or dizzy or passing out due to any heart condition. Our further research found that authoritative highway accident studies and statistics showed that there were many statistically far more likely causes of the accident and the

Insured’s death than sickness or illness. We also secured ems reports and police accident photographs that the insured did not have for its review.

Our Expert’s Opinion

We hired a highly-regarded forensic pathology expert (who had written a well-known textbook teaching forensic pathology to medical students) to review all of the evidence, gain an understanding of the exclusion at issue, and to see if he agreed with the autopsy report or securian’s expert physician.

In our expert’s opinion:

“a salient finding of the autopsy was that the brain weighed 1615 grams indicating a weight that on average is 200 grams heavier and thus signifying rapid swelling. The weight of the brain coupled with the catastrophic devastation of the vehicle after impacting the tree leads me to believe that one of the main reasons why mr. thompson died was closed head trauma characterized by traumatic disseminated axonal injury.

The above-described injury can create rapid brain swelling, deep coma and death and is in my opinion the reason of [the insured]’s death. Witnesses’ statements disclosed the physical activities of that day that included physical exertion and being active in excess of fourteen hours in an environment with elevated heat index and humidity.

Fainting due to electrolyte imbalance and/or exhaustion are more logical explanations for the collision or a simple case of distracted driving as aptly described by studies performed by the national transportation safety administration.

In summary, it is my opinion that death was due to multiple blunt force injuries based on the autopsy and crash scene findings and that the manner of death is accident.

It is further my opinion that there was no natural disease process that led to either death or incapacitation leading to the fatal collision.”

The Outcome

Securian reversed its denial and awarded full benefits.

Key takeaway 1

Without fully understanding the exclusion and how courts interpret it, hiring a top-notch expert to support our case, gathering the important evidence, and timely presenting them on appeal, we would not have likely won the case.

Key takeaway 2

Never give up when you’re right, and only hire the Best Experts when fighting big insurance companies.

Note that the final line of our expert’s report directly addresses the lack of causal contribution between any sickness or illness and Either The accident Or The cause of death. The exclusion at issue in the particular case must be directly addressed by the expert to be effective.

In sum, you need to understand the type of sickness and illness exclusion involved in your case, and how courts interpret it, to guide your appeal efforts as a whole.

The evidence gathered to support the above clients’ appeal, and especially the evidence gathered that was Not In the claim file at the outset, highlights our next step in the appeal process.

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Gather All Evidence to Support Your Appeal

Gather all existing documents and evidence relevant to your claim. To begin, include the insurance company’s denial letter, the insurance policy, and the insurance company’s entire claim file. They are required by law to give you a copy of the entire claim file free of charge if you request it. you’ll want to make this a written request, and send it by certified mail so that there’s a record of your request.

The claim file will typically include the following:

• Any police report rendered regarding the accident.
• Any medical records that detail the loved one’s medical conditions when they died, and any medication they take.
• Any ambulance report, other first-responder report, or emergency room record..
• Any autopsy report.
• Death certificate.
• Witness statements that may attest to the accident itself, the behavior and condition of the deceased before the accident, or any known medical condition.
• Reports by any expert witness that the insurance company relied on to support their denial.
• Photographs of the scene where the accident took place.

Next, decide what other evidence you can secure and present that can support your appeal that is not found in the claim file. This may include:

• Witness statements that can attest to the behavior and condition of the deceased before the accident, and the circumstances surrounding the accident.
• Any evidence that can challenge the accuracy of the denial or any insurance company expert’s opinion.
• Hiring an independent expert who can review all available evidence and might challenge the accuracy of the true cause of death
  

Write and Send Your Appeal Letter to The Insurance Company

Using the evidence of the initial claim file, any recovered missing evidence, the additional evidence you’ve built, the opinions of your own experts, the relevant policy provisions and caselaw, draft an appeal letter that presents in a compelling way your best factual, medical and legal arguments to recover the benefits you deserve. Include copies of all of the above documents, and send your appeal letter by certified mail to avoid any argument of untimeliness.

Even if the insurance company denies the appeal, the work you put into the appeal will be critical for your argument to the judge in federal court. All of the evidence you have added to the record on appeal will be available for the court to consider later, giving you the best chance of winning at that stage.

Final Thoughts

It’s really impossible to generalize the best way to build an appeal to fight an accidental death and dismemberment insurance denial based on a sickness or illness exclusion, because the strategies will be different depending on the facts of a given case. But understanding and following the steps above as a guide will significantly enhance your chances of overturning the insurer’s denial.

Consulting with an attorney experienced in dealing with these cases can provide the expertise and guidance needed for best chances to navigate this daunting process effectively. J. Price Mc Namara, disability, life, AD&D insurance attorneys exclusively handles denial claims, appeals, and litigation nationwide.

If you are fighting one of these denials, what i would suggest before you speak with the adjuster or do anything else concerning your claim, is to download our free book right here on this website, called “win your accidental death and dismemberment benefits appeal” From this website. It will help you avoid common mistakes that many people make when appealing these claims, and will tell you what insurance company traps and tricks you should look out for as you pursue your claim.

Better yet, contact our office and we’ll look at the particulars of your claim together if you’d like, and we’re happy to review your denial letter for free, at no cost to you.

Call or text (225) 201-8311 or complete a Free Case Evaluation form