When a loved one dies, life may seem to stop. Your grief may be deep, yet at the same time you must deal with funeral and estate plans as well as paying your loved one’s debts and bills. Many people rely on ERISA life insurance benefits to help pay their expenses after a family member passes away. Unfortunately, when a beneficiary makes a claim on a life insurance policy, the claim can sometimes be denied due to a preexisting condition exclusion. For life insurance, preexisting condition exclusion for life insurance and the laws that protect claimants—can be overwhelming and confusing. A skilled life insurance attorney may be able to help you understand what is going on and advise you on the best next steps.
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Reasons for Life Insurance Claim Denials
Life insurance companies governed by the Employee Retirement Income Security Act of 1974 (ERISA) have a variety of reasons as to why they deny claims—some fair and based on facts, others not so much. Common life insurance claim denial reasons include: - Preexisting conditions – if the insured had a history of heart disease and died from a stroke, heart attack, or similar medical event or condition, the insurance company may attempt to deny the claim
- Type of death – certain causes of death can be excluded from life insurance policies, usually risky or dangerous behaviors such as skydiving or scuba diving
- Failure to pay premiums – whether the insured simply forgot or could not afford their life insurance coverage, non-payment of premiums is a straightforward rationale for a life insurance carrier to deny a claim
Law Limits on Preexisting Condition Clauses
Most ERISA life insurance companies have a preexisting condition clause in their contract. This means that the insurance company may not pay out on the policy if certain medical conditions that could have contributed to the death are deemed present in the deceased based on medical records prior to their death. However, if a master group life insurance policy was issued prior to January 1, 1993, the insurance carrier is prohibited from using a look back period of more than 12 months after the effective date of the individual’s coverage. To further protect claimants, the same law also prohibits life insurance companies—ERISA-governed or otherwise—from including a definition of “preexisting condition” more specific or restrictive than that for a condition that would cause an ordinarily prudent person to seek medical care. At most, it can be defined as medical care such as treatment, advice, or diagnosis that was recommended or received within the prior 12 months before the effective coverage date. For more information about preexisting condition exclusion for life insurance, reach out to an accomplished attorney. Get Help with Preexisting Condition Exclusions for Life Insurance
