If you are one of the millions of Americans who pay premiums for accidental death and dismemberment insurance, you expect your policy to pay out if and when you need it to. However, several circumstances can change whether the insurance company pays such a claim or not. One of these circumstances is if alcohol is involved in an instance of death or dismemberment.

You may get AD&D either individually in the open market or through your employer. If your insurance comes through your employer, it will be subject to ERISA, and the benefits may be tax-free. If not, your policy will be subject only to state rules. If you paid the premiums, the benefits are not tax-free.

Insurance companies often take advantage of the intoxication exclusion for accidental death and dismemberment insurance to avoid paying out claims that involve any suspicions of alcohol use. If you or a family member were denied ERISA death and dismemberment benefits on the account of alcohol consumption, an experienced insurance attorney may be able to help.

Sometimes, however, after you or your loved one has filed a claim for benefits under an AD&D policy, the insurance company denies your claim. There are various reasons it will do so, and this means you should get an experienced insurance claims denial attorney to help you fight for the benefits you are due.

What is an Intoxication Exclusion?

An insurance policy is considered a contract between the insurance carrier and the insured. However, the insurance company can include various terms in their policy within the confines of federal and state laws.

Exclusions are common terms included in ERISA insurance policies, especially accidental death and dismemberment policies. These sections of policies may exclude deaths that occur at work or due to the gross negligence of the insured.

Some insurance carriers also have an intoxication exclusion. This means that if the insured is killed in an accident or needs to file a dismemberment claim, the insurance carrier may in certain states refuse to pay out on the policy if they determine the policyholder consumed alcohol or other intoxicating substances prior to their death or accident.

Intoxication Exclusion Laws

Each state has its own standing when it comes to insurance exclusion laws. Some have no regulations at all, instead opting to let individual insurance companies, claimants, and courts sort out these issues privately, while others specifically outlaw the practice.

There are many states that explicitly allow insurance companies to use this exclusion. ERISA insurance carriers are not legally mandated to cover any losses that result from the insured being intoxicated, or under the influence of drugs not prescribed to them by a physician.

Depending on how much alcohol was consumed and the specific situation, an insurance lawyer may be able to help claimants and their families access their accidental death and dismemberment insurance benefits. Some claimants may not have had enough alcohol or other substances in their system to have contributed to an accident.

For others, the insurance policy can be interpreted in more than one way. Insurance terms can be ambiguous, and certain parts of the contract may only apply to certain circumstances.

Insurance Companies Must Pay Claims

In Texas, the law requires that insurers deal with their insureds fairly and in good faith. Whenever a beneficiary files a claim against an insurance policy, the issuing insurance company is obliged to promptly investigate the claim and pay it if the investigation reveals no issues.

According to the Texas Supreme Court, however, this duty does not arise from the insurance policy itself. Indeed, the Court held that the breach of the duty of good faith gave the beneficiary a separate cause of action arising from the special relationship between an insurance company and its beneficiaries.

A cause of action for a breach of the duty of good faith and fair dealing is stated when the plaintiff alleges no reasonable basis for denial of a claim or a delay in payment, or even a failure on the part of the insurance company to decide whether it had a reasonable basis to deny or delay. In other words, your insurance company needs a very good reason to deny or delay payment to your beneficiary.

But, in Texas, the insurance company’s duty isn’t defined only by case law.

Chapter 541 of the Texas Insurance Code provides that you can sue your insurance company if your insurance company:

• Fails to settle in good faith when liability is reasonably clear
• Fails to reasonably explain why it denied your claim
• Fails to affirm or deny coverage within a reasonable time
• Refuses to pay a claim without conducting a reasonable investigation

Not only can you sue the company, you can also personally name adjusters and other insurance company personnel.

If The Insurance Company Denies Your Claim

If the insurance company denies your claim, you have the opportunity and right to appeal that decision. The past for doing so depends on who provides your policy. Even if the insurance company says the denial is final, you can appeal. If you purchased your policy on the open market yourself, state law may govern your appeal. Your time limit for filing your claim will be short, sometimes less than 90 days, so if you think you’re in this situation, don’t hesitate to obtain counsel.

If your employer provided your insurance, it is subject to the Employee Retirement Income Security Act (ERISA). ERISA’s rules and regulations are very complex, and in this case, your time frame is again short. Your best bet is to retain counsel quickly. In either case, you will have to appeal to the company first.

To do that, you should:

• Review the denial letter you received from the insurance company; it will tell you why the company denied the claim and how to appeal the decision.
• Gather your information to dispute the decision
• Request any documents you need from the insurance company—your policy, the forms and instructions for filing an appeal, and so on
• Submit your appeal request; make sure you’ve followed the instructions carefully.
• Follow up

Note that letting your attorney handle this entire process would make it far easier. This appeal process should be complete within thirty days of filing your completed package. Finally, if your policy is subject to ERISA, you must engage in this process before you can file suit in federal court.

Strategies For Denying Your Claim

Insurance companies attempt to deny your claim and engage in various tactics and strategies.

Some of these are:

• Delaying adjustment of your claim
• Delaying payment of your claim
• Misrepresenting terms of the policy, such as what “accident” means
• Pressuring you not to hire an attorney
• Ignoring parts of your claim during its investigation and adjustment
• Failing to communicate with you or your attorney
• Not providing reasons for the insurance company’s denial
• Failing to assign qualified personnel to adjust and investigate your claim
• Requesting unnecessary or irrelevant information or documents to delay the claim adjustment process
• Claiming the policy was void or lapsed
• Saying your accident wasn’t

If you believe your AD&D insurance company is engaging in these or similar tactics regarding your claim, you should immediately consult with experienced claims denial counsel. AD&D companies frequently deny claims, and if yours does, deal with it sooner than later.

J. Price McNamara concentrates his practice in dealing with insurance claims denials and will be pleased to assist you in recovering the benefits you deserve.

Hire ERISA Accidental Death and Dismemberment Insurance Lawyer to Fight Against Intoxication Exclusion

While it may seem easier to give up on a denied accidental death and dismemberment claim denial, this is exactly what the insurance carrier hopes you will do. If you fight your way through the confusion and advocate for your rights with the help of an insurance attorney well-seasoned in this area of the law, you may still be able to obtain benefits.

Appealing a denied AD&D claim, whether complex ERISA or state insurance rules govern your plan, can confuse anyone. J Price McNamara has extensive experience in handling AD&D claims and claims denials. He understands how insurance companies deny claims and will use that experience and understanding to advocate for your benefits under the denied claim. Don’t let your chance to recover pass you by.

Any experienced AD&D insurance lawyer should be familiar with the tactics that insurance companies may use to attempt a claim denial, and they should also have practice in refuting their reasons. Do not give up on your attempts to get this claim covered for you or a family member. Call on (225) 398-3076 today to schedule a consultation and get the professional help you need.