If you have suffered a significant injury or lost a loved one as a result of an accident, you have every right to exect that your insurance will provide the coverage promised in your policy.
When this doesn’t happen, the situation is frustrating. There is a lack of justice when the insurance company doesn’t honor the agreement. It is important to understand the basics of the system for accidental death and dismemberment (AD&D) insurance to ensure you get the disability coverage you deserve.
What is accidental death and dismemberment insurance?
Accidental death and dismemberment (AD&D) is a type of disability insurance coverage. It covers instances of serious accidents that result in death or major injuries. Unlike other types of insurance, it only covers injuries that result from accidents.
AD&D insurance is usually part of insurance packages provided by employers, and therefore it is covered by the Employment Retirement Income Security Act of 1974 (ERISA). ERISA is a body of legislation that regulates these insurance packages and their fulfillment. As a federal law, it overrides state insurance laws and provides significant protection for policy carriers.
Why are claims denied?
There are numerous reasons why insurance companies deny AD&D claims, the most common of which are:
- Exclusions: Every policy has a list of situations and events that render an otherwise covered injury not covered. Since these exclusions and exceptions are part of the contract, it is generally legally acceptable for insurance companies to not cover the things that are listed in the exceptions of the policy.
- Alternative causes: These policies cover only injuries and deaths caused by specific, covered accidents. If the injury or death was caused by something other than a specific accident that is covered in the policy, the insurance company will deny the claim. Other causes could be pre-existing conditions, other accidents that are not covered or other causes.
- Lack of evidence: The law does not assume that an accident was the cause of an injury or death; it must be proven. If no one saw the accident, or witness reports are conflicted, the legal assumption will be that the accident did not cause the death or injury, and therefore AD&D insurance is not required to cover it.
There are other reasons for claim denials, as well.
The problem is when insurance companies deny AD&D claims that are valid and covered. It takes a strong legal effort from an experienced ERISA lawyer to obtain the coverage benefits you deserve.
What can you do if your claim has been denied?
If your claim for AD&D coverage was denied, the good news is that you can still file an appeal. As an ERISA-covered claim, there are regulations and requirements that must be followed, and if your appeal is unsuccessful, you can bring your claim to a federal appeals court.
There are many people who’s claims are denied on the initial claim, yet ultimately obtain benefits through the appeals process.