You pay for insurance in case of an accident that leaves you with a severe injury or results in death. While insurance should provide benefits to you or your family, exclusions can leave policyholders with nothing. Insurance companies are ruthless and put a lot of thought into how they word their policies and do not pay benefits whenever possible.
The most common exclusion they use to deny benefits is intoxication. Most of the time, these clauses relate to driving while intoxicated, but there are cases where driving is not a factor.
Many insurance policies use intoxication exclusions with the premise of “law of the locale,” which means they will consider the local laws when determining whether you or your family can access benefits. There have been instances where a family cannot recover insurance benefits because the insurance company claims the policyholder was intoxicated at their death. You might receive a denial of disability coverage if the insurer claims your accident and disabling injury happened due to your intoxication.
Since insurance policies have many loopholes, companies can use them to get away with not paying. Always have an ERISA disability lawyer on your side who knows how these exclusions work and strategies you can use to get partial or complete benefits. One possible strategy is proving that intoxication was not the result of a death or disabling injury. Even if there is no denying that the person was intoxicated, a lawyer can prove it was irrelevant to the death or disability.
Consult with a disability or life insurance attorney to discuss your options for benefits.
A life insurance policy pays out claims to families when their loved one dies. These benefits should apply regardless of the reason for the death, but there are exceptions.
Life insurance further only works if the person dies within a designated time, which is vital in choosing the best policy for you. The older a person is will also affect whether they can purchase life insurance and the costs. The older you are, the higher your life insurance rate is, so it is best to look into these policies early. You can also purchase add-ons like AD&D insurance which we outline below.
Life insurance exclusions
Term life insurance has many exclusions, and it is essential to know what they are before filing a claim.
Life insurance plans exclude death due to intoxication, meaning there are no payouts for alcohol or drug overdose. However, you should review the language in the policy since it will impact the possible strategies your ERISA lawyer can use to ensure the family does have access to benefits. The insurer will need to prove that alcohol consumption was a direct or indirect cause of the death. Some states are making these exclusions illegal so confirm with an ERISA lawyer the validity of these exclusions.
There are additional common exclusions to life insurance benefits. For example, suicide within a year of the life insurance policy is an exemption, and the family will not receive full benefits. Conversely, some insurers do not allow beneficiaries to receive benefits if the suicide happens after the first 12 months. Review your policy for these exceptions.
If you have a medical condition, you must disclose it within your application. If a person does not disclose a medical condition and they die from the condition, the beneficiaries cannot obtain benefits due to the omissions. Some people do not disclose for fear of higher premiums, but it is worse to omit the condition, pay premiums, and not have access to benefits.
While homicide falls under life insurance, if there is an investigation showing conclusive evidence that the nominee took part in the homicide, no death benefits will be available.
Natural calamities are another exception, such as earthquakes, tsunamis, and floods. There are riders you can opt for that can provide some benefits for these situations. For all exclusions, policies are subject to interpretation, and while the insurance company has one, your ERISA lawyer and the court can have a different interpretation. That is the critical strategy in most denials.
Accidental Death and Dismemberment
Accidental death and dismemberment is a rider or add-on to health insurance or life insurance policies that cover the unintentional death or dismemberment of the person in the insurance policy. It provides benefits to surviving families upon death.
Dismemberment refers to the loss of body parts or bodily functions. Examples include loss of eyesight, hearing, or loss of limbs. It is not equivalent to life insurance and aims to cover unforeseen or uncommon events like falls, drowning, heavy equipment accidents, homicide, and traffic accidents.
Under an AD&D policy, the loss of limb results in the insurance providing payment for specific injuries like:
- Loss of limb
- Paralysis (permanent or partial)
- Loss of eyesight
- Loss of hearing
- Loss of speech
While these are examples, policies range in what they cover, and you must review yours to determine what is covered. You will also have to determine how much the insurer will pay since many do not pay full benefits. Some insurers will only pay if there is a combination of ailments. The severity of the loss of a limb will also determine what percentage of your lost income the insurance company will pay.
How exclusions work and defenses
The most common situation where the AD&D insurance company will try to deny a claim is when there is a death in a motor vehicle accident and the person is under the influence. While they might show the person was under the influence during the accident, they must show it was a significant factor. Suppose the person driving has a seizure or other medical condition that leads to a collision. In that case, an ERISA lawyer can show the court that the medical condition was the cause of death, not intoxication.
Additionally, the definition of an accident will come into play because the insurance company must define what they deem an accident. If they do not have a definition within the policy, they cannot deny certain claims. It is not unforeseen that an insurer should include explicit definitions of what they deem an accident and how intoxication contributes to accidents. Simply saying “accident” is ambiguous, and that leads to confusion.
Review the language in your accidental death and dismemberment policy, specifically regarding intoxication exclusions. Insurers must explicitly detail intoxication exclusions in their policy and not use ambiguous language left for interpretation. However, that ambiguous language helps policyholders to fight denials in court.
Another exclusion that insurance companies will attempt to cite is injuring oneself on purpose, which doesn’t apply in many cases. Being in a motor vehicle accident while intoxicated does not mean the person intentionally harmed themselves; they must have consciously decided to hurt themselves by aiming at a light pole and speeding into it.
Advantages and disadvantages of AD&D
The most significant advantage is surviving family members can access financial benefits to supplement the sudden loss of income which can lessen the burden on the family. Additionally, coverage is relatively inexpensive when you purchase a policy through an employer. It usually is a few dollars, but rates vary by employer and insurer. Depending on the insurer and policy, an individual policy can also have lower rates than life or disability coverage.
A significant disadvantage is these policies only cover specific events, and if there is a death or dismemberment outside of the particular circumstances, you cannot access these benefits. Another disadvantage is the benefit doesn’t move with you if it is employer-sponsored. If you leave an employer, the coverage will terminate. You will not get your premiums back and do not access benefits.
The insurance must prove more than intoxication.
If you are under the influence of drugs or alcohol when you suffer an injury, that does not automatically mean you lose your right to use your insurance policy. The insurance company must prove that the alcohol was a significant factor in causing the injury.
They will need to investigate the circumstances to find a link between alcohol consumption and the accident. There have been instances where while there was an intoxication exclusion, the plaintiff was intoxicated and suffered a debilitating injury and still received long-term disability benefits.
Do not assume that since you had a drink or two and suffered an injury, you cannot obtain benefits because many intricacies can impact the outcome. Additionally, intoxication exclusions will vary depending on the insurance policy. Some insurers do not include it at all, while others do. You must review your policy if you are unsure of intoxication exclusion or other exceptions.
ERISA offers protections and other benefits to ensure that insurance companies do not take advantage of injured policyholders. It is a federal program with few exclusions. If you get benefits through your employer, you have ERISA protections. Since insurance companies use vague language, it leaves the door open for interpretation and lawsuits.
Speak with an ERISA lawyer
When you file an initial claim, work with a long-term disability lawyer who knows the process for the best chance of obtaining benefits. If you already received a denial, employer-sponsored insurance policies have ERISA protections, so you can appeal to obtain your benefits. You might even need to file a federal lawsuit if your appeal does not result in a reversal decision. However, you must take steps before you reach this point, and you need the right attorney to navigate this process for you.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded J. Price McNamara ERISA Insurance Claim Attorney, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts