Acquiring an accidental death and dismemberment (AD&D) insurance policy is easy, but getting the insurance company to honor that policy and award benefits fairly is often difficult. Quite often, big insurance companies will deny payments for AD&D policies. The payout for this type of insurance tends to be hefty, so insurance companies will do whatever they can to avoid paying out benefits.
If an insurance company has denied you or a loved one benefits after a severe accidental injury or death, you will want to contact a Baton Rouge insurance dispute lawyer for death and dismemberment to handle your claim and help you receive the compensation you deserve for your pain and suffering.
At J. Price McNamara ERISA Insurance Claim Attorney, our legal team handles AD&D claims, and we regularly appeal denials for our clients. We work directly with insurance companies and take cases to federal court when necessary.
This demonstrates our dedication to success for our clients who deserve insurance benefits. Contact our office directly to learn how J. Price McNamara ERISA Insurance Claim Attorney might assist with your AD&D dispute.
Table of Contents
- What is Accidental Death and Dismemberment Insurance?
- Things to remember about AD&D Insurance
- Filing an Accidental Death Claim
- Why do AD&D claim denials happen?
- Reasons for Claim Denial
- What options do you have if you receive a claim denial?
- How Does the Appeal Process Work After a Denial of an AD&D Claim?
What is Accidental Death and Dismemberment Insurance?
Accidental death and dismemberment insurance is an additional insurance many people purchase because it is inexpensive and is often an add-on to their regular life insurance policies. Beneficiaries of an insured, usually a surviving spouse, child, or parent, receive a lump-sum payment if the insured dies in an accident. Individuals will receive living benefits if an accident causes the loss of bodily function, loss of limbs, or use of limbs. Many employers offer AD&D at very low rates to benefit their employees.
This insurance policy pays full benefits if the insured dies accidentally and will also pay out if the insured loses their eyesight, hearing, or a limb due to an accident
When offered by employers as part of an employee benefits package, this insurance is governed by the Employee Retirement Income Security Act (ERISA). The Employee Retirement Income Security Act of 1974 is a federal regulation that assigns minimum standards for most voluntary health and retirement in private businesses to afford protection for people enrolled in these plans.
Due to the unique nature and complexity of AD&D insurance, it is in your best interest to obtain legal counsel before filing your initial claim. An experienced AD&D lawyer familiar with ERISA will ensure that you properly file your AD&D claim and follow all protocols to promote a successful claim.
AD&D policies or riders are “double indemnity” riders. Double indemnity means that if a policyholder dies accidentally, his or her beneficiaries will receive benefits from the deceased insured’s regular life insurance policy and the accidental death rider. Most AD&D insurance payouts are equal to the face value of the policyholder’s original life insurance policy, so beneficiaries will receive double the payment.
This equals the original life insurance policy’s face value times two. Payouts for dismemberment tend to be less substantial, as the insurance company will pay a percentage of the original life insurance policy’s face value for the loss of sight, hearing, or speech, as well as partial or permanent paralysis, or the loss of a specific body part or limb.
Things to remember about AD&D Insurance
- AD&D insurance is usually an addition or rider to a life insurance policy. It is not automatic. It is often part of an employer’s benefits package.
- AD&D insurance pays out benefits when the insured dies accidentally, is dismembered, loses functions, or uses body parts because of an accident.
- AD&D insurance will always include coverage limitations. Read the entire policy to see what is and isn’t covered so you know what to expect.
- AD&D insurance does not pay if death was due to natural causes. The cause must be accidental.
- Accidental death benefits are often equal to two times the face amount of the insured’s life insurance policy. Dismemberment benefits are usually a percentage of the face amount of the insured’s life insurance face amount.
Filing an Accidental Death Claim
If your loved one has died in an accident and you are the beneficiary, you must file a claim with the deceased’s insurance company. You will need to supply the claims examiner with an accident report, witness statements, medical records (from before and after the accident), prescription information (from before and after the accident), toxicology reports, coroner’s reports, autopsy report, and a death certificate. Additional records and items may be necessary.
If any of the essential items are missing or inaccurate, this will give the insurance company reasons to delay or deny your claim. Providing all necessary documentation up front will help to avoid allegations of misrepresentation on your part. Hiring an AD&D insurance lawyer from J. Price McNamara ERISA Insurance Claim Attorney to file your claim may help prevent a delay or denial of your benefits.
Why do AD&D claim denials happen?
Unfortunately, even though beneficiaries pay their premiums and have ERISA protections, many AD&D claims end in denial. The ERISA insurance claims process for AD&D can be overwhelming, confusing, and difficult to follow. Often, claims get dismissed due to missing information or facts. One simple mistake with a claim can easily result in a denial. When this happens, an ERISA AD&D insurance lawyer can help.
AD&D payouts tend cost insurance companies a lot of money since they include double indemnity, so insurance companies will avoid compensating the insured’s beneficiaries. Big insurance companies often manipulate and take advantage of grieving families or victims of debilitating accidents and try to deny their benefits. They bank on victims’ and survivors’ lack of motivation to fight the denied claim. An experienced and compassionate insurance dispute attorney from J. Price McNamara ERISA Insurance Claim Attorney will fight on your behalf and demand a fair settlement.
Reasons for Claim Denial
Insurance companies come up with many reasons for denying benefits. Their reasoning often asserts that the death or dismemberment was not accidental. For example, what they consider to be an accident is subjective to each insurer. Limits and exclusions may vary depending on the policy, the insurer, and even the state you live in.
Reasons for denial can be surprising, but you can challenge them.
Common reasons for denial include:
- The insured’s death was on purpose or deliberate. The insurance company is implying the insured died from suicide.
- The insured’s reckless behavior caused the death or dismemberment. Reckless behavior may include skydiving, mountain climbing, or bungee jumping.
- The time between the accident and death or dismemberment is not immediate, invalidating the insurance policy. One example might be a person who experiences an accident but dies months later due to repercussions from the accident.
- The insured’s death was the result of a non-covered medical issue. Non-covered medical issues may include heart attacks, aneurysms, or strokes. For example, a person has a heart attack while driving. The insurer may claim that the death or dismemberment was not because of the accident.
- The insured’s death was due to alcohol or prescription drug abuse.
So, unfortunately, in many situations, beneficiaries are not only recovering from and learning to live with the sudden, accidental loss of a loved one, but they are also trying to figure out how to negotiate with insurance companies and receive what is rightly theirs. Insurance companies do not care about the grief and heartache of the beneficiary. They are often only concerned with the bottom line and ensuring they do not have to pay out a large sum of money.
What options do you have if you receive a claim denial?
Unfortunately, many claims receive denials. If the insurance company denies your initial claim, you can proceed to the administrative appeal phase. This appeal is critical and complex, and you need to take all the right steps in the appeal process. If you make any mistakes during the initial appeal, it can cost you your benefits.
Most accidental death insurance claims fall under ERISA, especially claims involving insurance plans that are part of employee benefits packages. Everything about the ERISA accidental insurance claim appeal is complicated. You can bet that the insurance company and their lawyers know how to work this confusing appeal system, but you, as a claimant, may not.
You always want to hire a knowledgeable lawyer at J. Price McNamara ERISA Insurance Claim Attorney. With experience in AD&D claims and appeals, not only can we handle your appeal and alleviate the extra stress you are experiencing, but we will also know how to plan appropriately and prepare for the possibility of court if your appeal gets denied.
Most beneficiaries file ERISA administrative appeals without assistance and guidance from an attorney. This usually ends in denial of the appeal and loss of benefits. This administrative appeal is your only chance to build support for your case. You must take the time and carefully gather vital evidence.
Note that this evidence will be the only evidence allowed to support your case if and when it goes to court. The proof you present during your appeal becomes a permanent part of the legal record before filing a suit. You cannot present additional evidence at that time. You will lose your case before you even start if you don’t have everything you need in the claim file to prove your claim is valid.
How Does the Appeal Process Work After a Denial of an AD&D Claim?
- You, as the beneficiary, will file an initial claim for AD&D benefits and receive a written denial from the insurance company.
- If ERISA governs your case, you must complete the administrative appeal with the insurance company. (If ERISA does not govern your accidental death insurance, you can go directly to the state court to file a lawsuit, you do not need to follow the appeal process.)
- You will only have 60 days to file an administrative appeal from receipt of the claim denial. If you miss this deadline, the insurer will not process your request for appeal, and you will lose benefits.
- The insurance company then has the final decision again. They will decide if they want to reverse their denial and pay your benefits.
- If the insurance company denies the appeal, which is often the way it goes, the claimant’s only option is to file a lawsuit in a federal court.
ERISA cases do not follow typical federal protocols. They have their own set of rules. An experienced ERISA lawyer will be comfortable with these intricacies and know how to proceed. That is why it is in your best interest to retain legal counsel. As stated earlier, the federal judge in an ERISA case cannot consider new evidence. Only evidence presented during the administrative appeal is reviewable in court, so your lawyer needs to present all evidence in the administrative appeal file.
The administrative appeal will require gathering all pertinent evidence, creating a solid case, and presenting a reasonable argument. This will consist of reviewing and analyzing the insurance company’s policy, denial letters, claim letters, and administrative records. It will also include finding evidence to support the claim, researching familiar legal settlements, and assembling all necessary documents.In one case requiring litigation, we received a $1.3 million trial verdict for our client, who had received a denial of their AD&D claim.
Documents usually required for an appeal include the death certificate, insurance policy, medical records, police records, toxicology reports, coroner’s reports, autopsy reports, eyewitness statements, and anything else helpful to prove your claim and reverse the insurance company’s decision to deny beneficiary benefits. This is a lot of work for someone grieving the recent loss of a loved one or recovering from a life-changing accident.
It is wise to hire a reputable insurance attorney with experience in AD&D claims and appeals to assist you with this litigation. At J. Price McNamara ERISA Insurance Claim Attorney, we have the resources and experience necessary to win a reversal of an insurance company’s decision and win you the AD&D benefits you deserve.
Your deceased loved one purchased that insurance policy, paid for those benefits, and expected that you and your family would have proper care and support if they died. Don’t let the insurance company deny the final wish of your loved one.
Call an Experienced Baton Rouge Insurance Dispute Lawyer Today
Contact an AD&D insurance lawyer at J. Price McNamara ERISA Insurance Claim Attorney today at our Baton Rouge office at (225) 201-8311. We will listen to your story and provide the guidance and support you need to fight for your beneficiary rights and find the peace and closure you need to move on with your life.
Having a claim for accidental death and dismemberment denied is very stressful. Our attorney can help you through the entire process, so you receive the benefits you deserve.
Baton Rouge Office
10455 Jefferson Hwy,
Suite 2B
Baton Rouge, LA 70809
Phone: 225-425-7917
Fax: (225) 201-8313
(By Appointment)
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