Accidental Death and Dismemberment Insurance Lawyer

Nationwide Representation For Accidental Death and Dismemberment Insurance Claim Denials

Receiving an insurance company’s denial letter for your accidental death and dismemberment benefits claim can come as a shock. You’re still dealing with the loss of a loved one. It’s overwhelming to now be thrown into the confusing legal world of claim denial, insurance policy definitions and exclusions, administrative appeals, and federal “ERISA” law. 

My advice, as a former insurance company attorney, is this: Don’t lose hope, and don’t take a claim denial as the end of the road. It’s not. Insurance companies issue wrongful denials of accidental death and dismemberment insurance claims every day. But you can appeal a denial, and you can still win your claim, either on appeal or in court. 

We discuss below the best practices for appealing a denied claim, and tell you step-by-step the process we use for our clients.

If you’re anxious about getting the next steps right without guessing, the following will help ease your mind, and most importantly, help you avoid common mistakes that many people make. 

Our law firm believes in empowering and educating our clients about best practices for winning your denied claim, not just giving you “general information” about insurance policies or claims. You can find “general information” anywhere.

Let a Former Insurance Attorney Guide You

The first several years of my career were spent representing insurance companies at a big law firm. I helped them avoid paying claims. But it quickly became apparent that many people working for the insurance companies felt pressured to derail and deny even legitimate claims when they could. The work was not fulfilling, and I finally quit. 

But everything happens for a reason. Working directly for insurance companies taught me and inspired me to guide insurance claimants to justice.  In my mind, NOTHING can replace the value of that “insider” experience with insurance company strategy to help my clients get their benefits paid, and avoid common mistakes.

That has been my mission I’ve loved for the past 25 years — guiding claimants and other attorneys through the complicated ERISA insurance claim and lawsuit process (more on what that is below) to win insurance benefits for deserving people. Fighting insurance denials all we do!

For a free legal consultation with a Insurance Claim lawyer serving Nationwide, call (225) 201-8311

3 Key Tips from Our Clients

Our clients shared that knowing these three things helped motivate them to operate from a position of strength when going against their insurance company:

1. This is not your fault, and you’re not alone. Insurance companies deny accidental death insurance claims, based on technical policy exclusions or other excuses that don’t seem fair, every day. 
2. Insurance companies are often wrong – and they know it. Their denials are often an illegal breach of their insurance contract, which was meant to protect you as its beneficiary.
3. Don’t give up! You have rights, and insurance companies are legally bound by their contractual obligations. They were paid good money for their promise of protection! You can appeal or take them to court, and you can win. The insurance company doesn’t have the final say. The law does.

Read on to learn, step-by-step, the best strategies to win your denied claim. 

Nationwide Accidental Death And Dismemberment Lawyer Near Me (225) 201-8311

1. As an Accidental Death Insurance Employee Benefits ERISA Attorney Who First Spent Years Representing Insurance Companies, I’ll Tell You How the Insurance Company is Plotting Behind Your Back (Don’t skip this…)

Be aware from the get-go that insurance companies do not want to be fair. They do not want to part with the many thousands of dollars they owe you. They have spent years developing their claim denial process to lead you down the denial path without getting advice until it’s too late. 

Reading this will give you a broad overview to understand the “big picture” of where you are on their denial path, their overall strategy, 3 things they hope you do (that you SHOULD NOT do) to ruin your chances of success, what you SHOULD do instead, and guidance on exactly how to do it.

Click to contact our insurance claim lawyers today

2. Common Exclusions or Reasons Why Insurance Companies Deny Accidental Death Insurance Claims (Yours Will Be One of Them)

The strategies to get your denied accidental death insurance claim approved will depend on the excuse the insurer gives for your claim denial. 

Below we list each of the most common insurance company excuses for not paying accidental death and dismemberment insurance claims (you’ll find your denial excuse among them). Further down, we also share the top strategies, in detail, to win against each of these excuses. 

Your denial letter will recite one of the following common excuses for not paying. Most of these excuses are based on policy exclusions written into the insurance policy. But while the exclusion might exist in the policy, the facts may not support its application to your claim.

a) Policy Exclusions for Alcohol or Intoxication Causing or Contributing to the Accidental Death:

• Alcohol or Intoxication caused or contributed to the accidental death
• Driving while intoxicated (DWI or DUI) caused or contributed to the accidental death
• Boating while intoxicated (DWI or DUI) caused or contributed to the accidental death
• Intoxication caused or contributed to an accidental death by drowning
• Intoxication caused or contributed to an accidental death by falling

b) Policy Exclusions for Alcohol or Intoxication Causing or Contributing to the Accidental Death:

• Illegal narcotic or drug overdose caused or contributed to the accidental death
• Illegal narcotic or drug caused or contributed to the accidental death
• Illegal narcotics or drugs combined with alcohol caused or contributed to the accidental death
• Prescription drug overdose caused or contributed to the accidental death
• Prescription drugs not prescribed or taken as prescribed by physician caused or contributed to accidental death
• Prescription drugs combined with alcohol caused or contributed to accidental death

c) Policy Exclusions for Accidental Death When Crime Related:

• Accidental death was during the commission of a felony
• Accidental death was during the commission of a misdemeanor
• Accidental death was during the commission of a crime

d) Policy Exclusions for Accidental Deaths “Contributed to” by Natural Causes, Sickness, Illness, Disease or Medical Treatment:

• Accidental death was not “accidental”
• Accidental death was “natural” or due to natural causes
• Death certificate says “natural” death even though death was truly caused by an accident
• Sickness, illness or disease caused or contributed to accidental death
• Medical treatment of sickness, illness or disease caused or contributed to accidental death
• Surgery caused or contributed to the accidental death

e) Other Excuses Insurance Companies Use to Deny Claims:

• Accidental death was suicide
• The accidental death insurance policy was not in effect at the time of accidental     death
• You aren’t the listed beneficiary on the accidental death insurance policy
• Someone else is claiming to be beneficiary, even though you are the listed beneficiary
• Accidental death victim failed to disclose a medical condition on insurance application, or “non-disclosure”
• An “Interpleader” lawsuit is filed by the insurance company so the court can declare the right beneficiary

Complete a Free Case Evaluation form now

3. The Three Phases of an Accidental Death and Dismemberment Insurance Claim

An ERISA accidental death insurance claim has three important phases – the initial application phase (and if denied), the administrative appeal phase (and if denied on appeal), the litigation/court phase. Each phase has complexities of its own.

The administrative appeal phase, more than anything else, determines the outcome of an ERISA insurance benefit claim. It’s also where most tactical mistakes are made. These mistakes can be avoided by better understanding the ERISA process.

We’ll begin assuming you’ve received a denial letter after the initial application phase but have not yet appealed. The most important things to know are:

• The overall insurance company claim denial strategy;
• The three ways the insurance company hopes you react to its denial letter;
• The ONE way you should respond to the insurance company’s denial instead, and why.

Let’s break it down.

4. The Overall Insurance Company Claim Denial Strategy

It’s important to know that insurance companies have an overall strategy that applies to all claim denials.

And it’s this: Exhaust, frustrate, and confuse the claimant. That sounds cynical, I know. But trust me, I’ve seen it from the inside, and it’s the absolute truth. 

When the insurance company denies your benefits, they know you’re already exhausted from all that comes with your loss. So they want to further exhaust and frustrate you with their claim process to discourage you from fighting at all, or to appeal in a way that can’t help you win.

Their denial letter gives you their excuse why the policy you paid for doesn’t provide coverage, and says that under “ERISA law” you can “appeal.” The law requires that they put that in the denial letter. But they obviously don’t want to pay your benefits, so they give you no guidance on how to appeal with any chance of winning. 

Which leaves you confused: How long should an appeal be? What should I say? What traps should I avoid? What additional records, expert reports, witness statements or other evidence will help me win? Do I even have a chance of recovering my benefits?

Every unique claim, depending on the claim denial reason, has a unique best path for you to follow to recover benefits and financial security for your family. They do not want you to know what that path is.

But all claims, regardless of the reason for the claim denial, have universal paths to avoid. The insurance company not only knows this, but actually tries to lead you unknowingly down these paths, likely resulting in permanent loss of benefits. 

5. The Three Ways the Insurance Company Hopes You React to its Denial Letter – Don’t Do This

The insurance company hopes you react to its denial of benefits out of exhaustion and frustration in one of three ways:

1. You give up and go away, thinking they’re right or that you can’t win; or 
2. You wait too long and miss your deadline to appeal; or
3. You file an “appeal”, either yourself, or through an attorney who is unfamiliar with ERISA law, that passionately argues with logic and reason why your claim denial was wrong, reacting without taking the time to get advice or research to learn that this will not help you one bit. (Most claimants and attorneys unfamiliar with federal ERISA law make this mistake. An ERISA attorney would never do this.)

The first way they hope you react, giving up, is obviously an easy win for the insurance company.

The second way they hope you react is by missing your appeal deadline. If the claim is governed by ERISA, as most are, a mandatory administrative appeal process is required by ERISA before a claimant can file suit to challenge a denial of benefits. The claimant must file the administrative appeal with the same insurance company that denied the claim. Then that same insurance company, which also must pay benefits if it reverses itself, decides whether or not to reverse itself and pay benefits – crazy but true.

**WARNING: Typically, the deadline for filing an administrative appeal on a denied Accidental Death Insurance claim is typically 60 days from the date of the written denial.

Missing an administrative appeal deadline is as fatal to a claim as the passing of a statute of limitations with very few exceptions. Missing it means the claim is over, and the denial cannot be challenged. And the appeal is mandatory. You can’t decide to skip the appeal and file suit in court when you receive an initial denial letter. This deadline applies to claims governed by federal ERISA law, and most are. Whether your claim is governed by ERISA law is explained below. If yours is, your denial letter should mention the word ERISA.

If the Accidental Death Insurance company again denies benefits following a timely administrative appeal (a very common outcome), the claimant can only then file a lawsuit, which must be filed in federal court. State court is without jurisdiction.

The third way Why would the insurance company want you or an attorney to file an appeal that passionately argues with logic and reason why your claim denial was wrong? And how could this reaction hurt your chances of winning your claim?

Because, as the insurance company knows, by choosing that route, you will lose your last and best chance of getting benefits. Why? Because they know that ERISA law prohibits the court from considering any evidence that you don’t submit with your appeal before filing suit. (Most claimants and attorneys unfamiliar with ERISA law don’t realize this until it’s too late.) 

In other words, most claimants and attorneys think that if the insurer denies your appeal, they can file a lawsuit. Then they can put in more effort later, and get stronger evidence together to present to the court to support their claim. 

That is the way “normal” lawsuits work. But it’s not the way an ERISA lawsuit works, and your claim is most likely governed by ERISA law. An appeal passionately arguing your claim with logic and reason wastes your last chance to build the evidence into your case that it takes to win.

EXAMPLE From one of Our Clients’ Cases:

The following example is from an ERISA case we won in federal district court for an actual accidental death and dismemberment insurance client, whose claim was initially denied under an “intoxication” exclusion, then again denied on administrative appeal. It serves as a perfect example of why you need to include all available helpful evidence as part of your appeal evidence.

In that case, Jim (not his real name) was fishing with three friends in Port Aransas Aransas, Texas,  near Corpus Christi, Texas. After fishing, later in the afternoon, they boated to a spot in Aransas Bay popular for anchoring and swimming to cool off.  Once anchored, Jim dove from the rear deck of the bay boat.  Unfortunately, the water was murky, and he couldn’t see that where he dove was a shallow sandbar only 2.5 ft. deep. Mr. Sewell struck his head on the bottom, was instantly paralyzed from the neck down.

Jim filed a claim for his employment-based accidental death and dismemberment insurance benefits. The insurer denied the claim claiming an “intoxication” exclusion barred coverage. This was based on the initial hospital lab report showing a high blood-alcohol content. 

He hired us as his attorney to appeal the claim, and we could see that much more evidence was needed to defeat the denial. We hired a toxicologist, and got sworn affidavits that the boaters had relatively little alcohol (beer) spread out over the day, and that nobody, including Jim, showed any signs of intoxication. Our expert toxicologist also cast doubt on the accuracy of the lab result. We included this evidence, and much more, with our appeal submission. Still, the insurer denied the claim on appeal.

We filed suit in federal court, and the Court ultimately ruled in Jim’s favor, based not only on our legal arguments, but most importantly, on the evidence we submitted on appeal. The insurer appealed to the United States Fifth Circuit Court of appeal, and the case settled for a confidential amount.

The main takeaway here is that without submitting that evidence with the appeal, we would not have been permitted under ERISA law to bring that evidence to court for consideration at all.  Jim would not have won his benefits.

You can read the Court’s opinion by Googling this: Timothy Sewell v. The Lincoln National Life Insurance Company, Civil Action No. 2:23-cv-00317, United States District Court, Southern District of Texas, Corpus Christi Division. 2025 WL 1276005.

So the administrative appeal is your only chance to gather, create and build the best evidence to support your case later in court. The evidence you submit during the administrative appeal process becomes part of that record that the court can later consider. Whatever case you build (or don’t) is carved in stone before you ever file suit.

The insurance companies and their attorneys know this. So they load the administrative record with evidence and reports of their own consulting “experts” favorable to their position in denying the claim. They hope you’ll just “argue” on appeal.

They also know that most claimants and many attorneys don’t know this. So most claimants and many attorneys file “administrative appeals”, but submit no supporting evidence beyond medical records. They basically argue how unfair the denial is after they paid policy premiums for years. The arguments may be true, but they are not “evidence” that the insurance company or the court must consider. Filing an administrative appeal this way does absolutely nothing to help the claim, and it’s exactly what the insurance company hopes a claimant will do. It wastes the claimant’s best and only opportunity to build the best case for reversal, either on administrative appeal, or in court if the insurer denies the claim again.

That the administrative appeal makes or breaks your case cannot be overstated. It is during this process, before a lawsuit can even be filed, that most claimants lose without realizing it.

So how should you respond (not react) to the insurance company’s denial letter?

6. The One Way You Should Respond to the Insurance Company’s Denial Letter, and Why

You should respond to the denial letter by doing exactly what the insurance company doesn’t want you to do. 

That is, you BUILD your claim and appeal strategically with NEW EVIDENCE (not just ARGUMENT, but EVIDENCE), using a tried and true PROCESS that PROVES your claim the way the insurance company knows will stand up in court if they deny your appeal. 

That’s what wins accidental death and dismemberment benefit claims and appeals – both appeals and lawsuits, and the years of future financial security you paid to protect. Avoiding pitfalls and getting it right is critical.

Read on to learn step-by-step how to BUILD a winning claim and appeal for the most common exclusions and reasons why insurance companies deny these claims.

7. How to Build a Winning Accidental Death and Dismemberment Claim and Appeal Step-by-Step

Building the best administrative appeal for an Accidental Death Insurance claim denial requires a process. Beginning with the potential end in mind (federal court), you’ll want to use the administrative appeal process to gather, create and introduce ALL available supporting evidence into the administrative record. Any evidence you submit to the insurance company in the process becomes part of that record. That record is ultimately filed into the court record if a lawsuit becomes necessary, and it forms the only evidence the court can consider.

So where to start? 

The process we follow, described below, will help guide you to develop the nuts and bolts of a strong, well-supported administrative appeal.

a) Evaluate the Accidental Death Insurance Company’s Denial Letters

We evaluate the written reasons given by the Accidental Death Insurance company for denying the claim. This serves as our primary roadmap for what and where our focus needs to be.

b) Analyze Every Page of the Accidental Death Insurance Company’s Claim File or Administrative Record

The Insurance company is required to provide, upon written request, and free of charge, its entire claim file/administrative record. It’s often over a thousand pages long.  We review every page, and we always find information there helpful to the case. 

It consists of all medical, investigative, and other evidence the insurance company gathered, and the insurance company’s own consulting medical and other expert opinions and reports. Sometimes this information contradicts the insurance company’s reasons for denial, which can be very helpful. Other times the evidence on which the denial was based is purely speculative. 

The claim file also includes internal insurance company personnel emails discussing the claim. Sometimes these communications indicate disagreement among insurance company personnel on whether the claim should be denied or approved. Internal insurance company claim notes, emails, records of telephone conversations with the client and others, and employer-provided documents. These documents are usually together in one section of the claim file, but may be found in more than one place. This part of the file may be anywhere between 20 and 100 pages or more. Here is where you will usually find the insurance company’s summarized history of the client’s claim from beginning to end, and the thoughts of the insurance company employees during the course of the claim process.

The insurance company is required to include all documents and evidence generated in connection with the claim WHETHER OR NOT the insurance company relied upon it to support the denial.

Much more is there in the administrative record than is mentioned in the insurance company’s denial letters. We often find evidence that directly contradicts the insurance company’s denial, or a lack of evidence to support the over-stated reasons it gave to support the denial of a claim.

EXAMPLE From another one Our Clients’ Cases:

The following ERISA case was also also won in court for another actual accidental death and dismemberment insurance client, whose claim and appeal were both denied under an intoxication exclusion. It serves as a perfect example to highlight the importance of reading every page of the claim file:

In that case, our client Jane (not her real name) lost her husband in a terrible head-on automobile crash. She miraculously survived as his front seat passenger. The husband was insured by a GIGNA accidental death and dismemberment policy that he had as an employee benefit. His blood lab results detected several prescription narcotics for which he did not have a prescription.

We demanded a copy of the claim file as we always do. Buried in the voluminous claim file, we found a mere two pages of critical evidence: the insurance company’s own expert toxicologist’s opinion report which directly contradicted the insurance company’s claim that the prescription drugs detected in the husband’s blood caused the accident.

The United States Fifth Circuit Court of Appeals found in that case that CIGNA had illegally withheld that expert’s report from my client. The Court ruled in her favor awarding full policy benefits. 

The takeaway here is that without reviewing every page of that 1000 plus page record to find the buried report, our client would not have received the benefits she needed and deserved. 

(You can Google White v. Life Insurance Company of North America (CIGNA), 892 F.3d 762 (5th Cir. 2018), as revised (Jun 14, 2018) to read the full court opinion.

Listen to the official recording of the attorneys’ oral argument for the case before the United States Fifth Circuit Court of Appeals.

If interested, you can also listen to CIGNA counsel’s and my oral arguments, and the court’s vocal suspicions, by clicking this link. (You might find it an eye-opener on how far an accidental death insurance company will go to avoid a big payout by arguing an intoxication exclusion.)

We also need to determine what supportive medical or other available evidence we deem important is not in this record, so we can obtain and include any such evidence as part of our appeal. That way it becomes part of the administrative record which can later be considered by the court if the claim is denied on administrative appeal.

c) Review the Accidental Death Insurance Policy, and any ERISA Plan and Summary Plan Description

You can request these documents directly from the insurance company, the ERISA Plan Administrator or the employer’s human resources department. They are required by law to give you these documents or face a stiff fine if they refuse or ignore you.

We analyze all policy language, especially any exclusions the insurance company relies upon to support its denial. The exact wording of the policy language exclusions can vary from policy to policy, and subtle variations can be outcome determinative. The policy language also drives exactly what evidence the claimant should gather, present and add to the administrative record to support entitlement to benefits under the policy, and refute the insurance companies evidence or assumptions.

We sometimes find that the insurance company wrongfully denies a claim based on policy language or exclusions of an older or newer version of the policy that is more favorable to the insurance company, but doesn’t even apply to your case. Or, we may find that the insurance company is seeking to use an unfavorable (to you) policy amendment that doesn’t apply to the case to wrongfully deny the claim. 

In other cases we find that a policy provision the insurance company is using to deny a claim is ambiguous, or contradicted by other insurance policy provisions, making the denial legally unenforceable.

The entire policy should be read carefully to determine ANY provisions that undermine the insurance company’s claim denial.

d) Gather Death Certificate, Medical, Toxicology, Coroner and Autopsy Records to See if They Support the Accidental Death Insurance Claim and Supplement Where Needed

Depending on the reasons for the denial of an Accidental Death Insurance claim, the death certificate, medical, toxicology, Coroner and autopsy records are ALWAYS important. Some of these may be supportive of the claim, but missing from the insurance company’s administrative record or claim file. Others may have errors hurting your claim that need to be corrected, and the corrected versions re-submitted to the insurance company with your appeal.  

We gather, review, study and summarize all such records. Here, we look for areas of potential strengths, weaknesses or the absence of evidence needed for claim support. The focus is to determine where we need to build evidence that supports our claim, or contradicts, or otherwise negatively addresses the reasons the Insurance company gives to support its denial of benefits.

When Physicians, Coroners or other involved professionals write their reports, they are not necessarily attempting to cover all information in the kind of detail needed to support an Accidental Death Insurance claim. They often rely on computer programs when preparing their notes that simply do not have fields concerning the evidence necessary to support a claim, or auto-fill features that generate errors. 

In the case of a death certificate, the Coroner simply fills in blanks on a government form, which may leave information critical to the claim unspoken. So the support needed may seem to be weak or absent. They often don’t state opinions or factual observations in enough detail. The insurance companies then cite “lack of evidence” to support the claim denial, or take single words from a death certificate out of context with other evidence. That evidence may in reality exist, but it’s just not stated in the records. Sometimes the death certificate, medical, or other records contain plain errors that hurt the claim. Insurance companies know all of this, and know how to exploit these inaccuracies.

e) Think About Basic Information You May Know to Support the Claim

Remember in ERISA cases you have only 60 days to file the appeal for a denied accidental death and dismemberment insurance cliam. So you need to really focus on gathering any helpful evidence, and quickly.

We interview the client to determine relevant details about the claim. This lets us get to know them better and gives us our foundation to build upon. Think about all relevant information you know, as well as what relevant factual knowledge family members, coworkers or friends can provide in affidavits to support the claim, or refute the insurance company’s reason for denial. 

For any first-responders or witnesses to the accident in question, what might they know that would help support the claim? Contact them and question them and ask for a written statement if they have helpful information. 

Also important is to determine what medical or other records may exist to help support the claim that weren’t considered by the insurance company during the initial claim process. This may include medical records, autopsy reports, toxicology reports, accident investigation reports or other documents, depending on the reason for the denial.

EXAMPLE From another one of Our Clients’ Cases:

The following example is from another case we won on appeal for an actual accidental death and dismemberment insurance client, whose claim was initially denied because the insured’s death was “not accidental”, but instead was “contributed to” by sickness or illness, and therefore excluded from coverage. The case serves as a perfect example of why you need to find any available helpful evidence that was not considered by the insurance company, and include it as part of your appeal evidence.

In that case, Securian Insurance Company denied our client Mary’s (not her real name) claim for AD&D benefits when Securian’s insured’s pickup truck drifted off the highway and crashed into a tree at high speed. He died at the scene. Securian denied the claim after both the Coroner and Securian’s expert physician agreed that the insured’s heart disease contributed to his death by either causing him to lose consciousness and drift off the road, or alternatively, contributed to his death because the crash would not have resulted in a healthy person’s death. 

We obtained Police photographs and a First Responder EMS Report that the Coroner and Securian’s physician did not review before forming their opinions. The photographs showed that the insured’s truck was demolished in such a way that it looked like anyone would have died in the crash. 

The First Responder EMS Report said that the insured was still alive when they arrived on the scene. But Securian’s expert physician had based his opinion that heart disease contributed on the false assumption that he was deceased before EMS arrived. We also hired an expert forensic pathologist to review all records and all photographs. He concluded that no sickness or illness contributed to the accident or to the death itself.

The main takeaway here is that without hiring an expert forensic pathologist, and submitting that evidence that the insurance company had not considered before with the appeal,  Mary would not have won her benefits, and the insurer would have known that chances for Mary in court would have been slim.

Exactly what information is relevant and important to a successful Accidental Death Insurance claim will vary based upon the reasons the insurance company gives for denying the claim. Remember, the insurance company doesn’t go out of its way to gather evidence it thinks will help get you paid. Just the opposite is true. These claims involve large sums of money the insurance company would rather not pay.

f) Build and Execute

Wherever you find weaknesses, the absence of important evidence or errors in the records, correct the problems using a number of different approaches depending on the case at hand. 

For instance, you may need to get input from treating Physicians, Coroners or other medical experts as needed for the particular case to provide more detailed explanations to correct critical errors. You may need to ask treating Physicians to address certain issues not previously sufficiently addressed specifically and in detail in a report. In some cases you may need to retain additional experts of various specialties to review other evidence and provide reports of their opinions to support the claim and shoot down the insurance company’s reasons for denying the claim.

Sometimes meeting face-to-face with treating Physicians and other involved experts to determine their opinions on relevant details is helpful. Whatever the weakness or absence of evidence or error in the medical records might be, you do everything you can to correct it. 

Again, the important thing is that all evidence building, supplementing or correcting has to be done during the administrative appeal process and put into the administrative record as part of the administrative appeal. Otherwise it’s useless, as the court can’t consider it if introduced later.

This process must be accomplished thoroughly, but also rapidly due to the deadlines as outlined above.

g) Decide What Additional Evidence May be Helpful

At this point, we determine what, if any additional medical or other forms of evidence not forming part of the administrative record might be helpful to support the case. This varies from case to case, but may include additional affidavits of family members, friends or coworkers regarding any important facts or issues within their knowledge that aren’t otherwise addressed. 

h) Conduct Legal Research

We conduct nationwide computer research, combing for judicial opinions factually similar or otherwise supportive of the claim and our legal arguments. We save these so we can later cite to them and quote portions of them to support our arguments to the insurance company, and later to the court if necessary.

i) Construct the Best Administrative Appeal Argument

We then again analyze and dismantle the written reasons given by the insurance company for denying the claim. We do this by using everything helpful we find from all of the above efforts, and assemble it into a concise, impactful argument. It’s a blended argument of our strongest facts, woven together with our strongest legal arguments, citing relevant policy provisions, the administrative record and our new evidence which will now be submitted and become part of that record as part of our appeal. It’s constructed much like a legal brief filed in court, tailored to follow the same pattern the court will use analyze the case. The insurance companies will know you have built a solid case to be taken to court if they again deny the claim.

j) Final Review

Before we submit our administrative appeal argument and supporting evidence to the insurance company (which will ultimately be our argument to the court), we examine our argument again in detail to determine whether it triggers new ideas for any additional evidence which may be supportive. 

k) Submit the Best Administrative Appeal Argument and Await a Decision

After we feel that we’ve left no stone unturned, and have crafted our very best arguments in favor of the claim, we submit our administrative appeal, along with all supporting documentation that was not already part of the original administrative record, to the insurance company. We send this by certified mail to avoid any argument by the insurance company that it was not sent within the legal deadline for appealing.

If the insurance company reverses its denial, great! If it doesn’t, your efforts, evidence and arguments will still be useful in the lawsuit that follows. Be sure to request an updated copy of the administrative record and make sure that it includes all of the evidence you submitted. This will help to avoid a later argument in court about the completeness of the administrative record to be considered by the judge. 

Following the above steps will give you the best chances of getting your benefit denial reversed on administrative appeal. But equally important, if your claim is denied on administrative appeal, you have built the strongest record possible for getting the denial reversed in federal court.

8. The ERISA Federal Court Lawsuit

A bit about the ERISA federal lawsuit that follows a claim denial on appeal helps again highlight the importance of the administrative appeal.  An ERISA insurance claim lawsuit in federal court is different from others. It doesn’t follow the typical federal procedural path.

Most federal district courts use special scheduling orders tailored specifically to the unique way ERISA cases reach court resolution. ERISA has its own statutory venue rules. Discovery is restricted, really almost nonexistent. The parties have no right to a jury trial. No witness testimony is presented. The only “trial” at all is a trial on briefs referencing the administrative record filed with the court, either on cross-motions for summary judgment or simply motions for judgment on the administrative record. 

The court reviews a denial under an “abuse of discretion” standard, requiring it to give great deference to the financially- conflicted insurance company’s decision. Courts have even upheld the insurance company’s administrative appeal decision while expressly stating that it is contrary to how the court would have ruled independently on the evidence. 

Choice of venue and choice of law considerations are critical because they can impact the standard of review, as some states have laws prohibiting “abuse of discretion” review, and such laws apply in ERISA cases. Most of the governing substantive law, however, is either ERISA-specific or federal common law jurisprudence, with much disagreement on many issues among and even within federal court jurisdictions.

But most important, again, and most pertinent to the impact of the administrative appeal, the federal judge in an ERISA case cannot consider any evidence that was not made part of the administrative record, during the administrative appeal process, before suit is filed.

If the insurance company denies your appeal, by following the above process, you have built the best and strongest possible administrative record evidence to win in federal court. 

9. Why Does Federal ERISA Law Apply to Most Accidental Death Insurance Claims Filed in the U.S., And Why Does It Matter?

The majority of Accidental Death Insurance claims in the U.S. are governed by the federal ERISA (Employee Retirement Income Security Act of 1974) statute. With a few exceptions, ERISA governs all Accidental Death Insurance claims involving insurance policies or plans which form part of employee benefits package. So most claim denials fall under ERISA law.

Yet handling an ERISA Accidental Death Insurance claim, from the administrative appeal to the federal court lawsuit, is a complex minefield for the unfamiliar. Everything about it is different. Insurance companies and their attorneys know and understand how to use ERISA’s complexities to their advantage. But claimants, and often their attorneys, typically don’t until it’s too late.

ERISA law is also terrible for the accidental death and dismemberment insurance claimant, and gives great advantage to the insurance company. It may be the worst law ever written, and it makes long term disability claims hard to win. All over the books you can read the frustration of federal judges at feeling ERISA-bound to render unfair judgments.  

Here’s a quote from just one:

“Occasionally, a statute comes along that is so poorly contemplated by the draftspersons that it cannot be saved by judicial interpretation, innovation, or manipulation. It becomes a litigant’s plaything and a judge’s nightmare. ERISA falls into this category…. stands for ‘Everything Ridiculous Imagined Since Adam.’… is beyond redemption. No matter how hard the courts have tried, and they have not tried hard enough, they have not been able to elucidate ERISA in ways that will accomplish the purposes Congress claimed to have in mind.”

William Acker, Jr. Judge, U.S.D.C., N.D. AL Can the Courts Rescue ERISA, 29 Cumb.L.Rev. 285, 285-86 (1999).

Unfortunately, most claimants file ERISA administrative appeals unrepresented, or represented by attorneys unfamiliar with ERISA law. The result is often the permanent loss of a benefits claim that could and should have been successful. 

Understanding the above will help to avoid unnecessary losses.

10. Additional Helpful Accidental Death and Dismemberment Insurance Information

Accidental Death & Dismemberment (AD&D) insurance is a supplement to a life insurance policy that will pay benefits if the insured dies in an accident, subject to a number of exclusions as noted above. The policy may also pay lesser amounts for “dismemberment”, including the loss of sight, hearing, or a limb, or loss of use of body parts due to an accident. AD&D is much cheaper than traditional life insurance, but it is only an add-on to whole or term life insurance, not a replacement for them.

The law firm of J. Price McNamara: Disability, Life, AD&D Insurance Attorneys handles only life insurance, accidental death and dismemberment insurance, and disability insurance claims. This is our sole area of focus. 

Contact our law firm today at 225-438-9157 if we can help with any questions you might have.

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