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Originally Posted On: https://www.lassenlaw.com/contesting-a-denied-ad-d-insurance-claim
Accidents happen, and severe and sometimes fatal injuries can result. In anticipation of such potential realities, consumers will often look for an insurance policy that covers events of accidental death and dismemberment (A D&D). Although such a policy’s language seems pretty straight forward, what these policies cover is not so simple. As a result, this leaves a vast chasm of potential disputes resulting from an insurer refusing to cover a party under this coverage.
Although denials of coverage are often used as a way for insurers to avoid paying disputable claims, this does not free them from potential liability, especially if a suit is brought that requests that a judge or jury enforce the terms of the policy.
A D&D Coverage Explained
There are two different types of A D&D policies on the market today. The first option is for the consumer to purchase a rider to a preexisting life insurance policy that will provide additional coverage for injuries and death benefits beyond the standard life insurance coverage. The second option is to purchase an A D&D policy that is independent from all other insurance coverage.
An excellent example of when A D&D insurance is effective is when you suffer an injury that could allow you to collect anywhere from 50-100 percent of the total death benefit covered even if the accident itself is not fatal. This coverage can especially be useful if your injury is not fully covered by other insurance policies, including third-party coverage, where the third party is considered to be at fault for the accident.
In the event of a fatal accident, A D&D coverage can provide an added death benefit to be distributed to your beneficiaries above and beyond any other life insurance coverage.
Reasons Insurers Deny Coverage
AD&D insurance policies are full of exclusions that give the insurer a basis to deny a claim. Some of these exceptions included:
- Substance abuse
- Coverage is not authorized under the terms of the policy even if an accident did occur
- The A D&D policy was not in effect at the time of the incident
- The injuries or death were the cause of a prior medical condition; or
- Third-party liability was the cause of the injury or death, such as medical malpractice
One of the most challenging aspects of holding an A D&D policy is understanding the details of what the policy covers. With the typical number of exclusions touching on a wide range of potential scenarios, it can be easy for the insurer to use the policy’s vague language to justify a denial of coverage. This denial can especially come into play if the damages claimed would require a maxing out of the coverage limit. In these scenarios, insurers will often look for ways to leverage the denial of the claim to negotiate a lesser payout. This tactic may not necessarily be based on a valid argument that the policy exclusions apply. Instead, it is a way to instill doubt that the insured party is entitled to the amount of compensation they are claiming. In these cases, you need to prepare for the process insurance companies will go through to vet your claim.
The first step in pushing back against a denial of coverage is to prepare for the investigation conducted by the insurance company. This investigation can include a review of your medical records, both pre and post-accident. The investigation may also include an insurance adjuster or attorney interviewing witnesses to the accident and collateral witnesses who can testify to your condition both before and after the accident. Employers and co-workers may also be interviewed so that the insurer can determine whether or not you were out of work for a prolonged period of time due to the injury.
Most A D&D policies require that the covered party fully cooperate with the investigation by signing releases to allow the insurance company access to all medical and employment records. An investigator or adjuster will also have the right to conduct interviews of the policyholder and others to analyze the validity of the claim. These interviews are often performed under oath, meaning that the insured must swear that the testimony they are providing is correct.
The most important part of preparing for the investigation is to ensure that you have a complete copy of your medical file before the insurer makes a formal demand. Most A D&D policies have specific language that states that an insured’s failure to cooperate with an investigation can be a basis for denial of a claim. Insurance adjusters are well trained to document their attempts at securing information. If they can show that the covered party has ignored or neglected to provide complete information, this can result in their issuance of a denial based on a perceived failure to cooperate, which can be argued is a violation of the policy.
Laying The Groundwork For A Lawsuit
Similar to how adjusters are trained to document their attempts to investigate a claim, you should also be prepared to build a foundation for a lawsuit should the insurer continue to deny your claim. Organizing your medical records, putting your witnesses on notice, and evaluating the law that supports your request for coverage are all essential steps that will get you ready for the process of disputing your denied claim in court.
Insurance companies will come ready to dispute every claim they can based on the vagueness of their policy. You must also come prepared with the right legal team to fight back so you can be provided with the compensation you deserve through your A D&D policy. This fight may take time and effort, but through proper coordination and through a careful presentation of evidence, insurance companies will be put on notice that they are at significant exposure should they continue to deny a lawful claim for compensation.