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What is Covered Under My Accidental Death or Dismemberment Policy

How Do I Get the Insurance Company to Pay?

Accidental death and dismemberment insurance, or AD&D as it is commonly referred to, provides a lump sum payment to the beneficiary in case of accidental injury or death. AD&D policies can provide upwards of $1 million of coverage with very low premiums. Because of the low cost, it is often offered by employers. However, only a few very specific courses of events causing the injury or death will result in payment under the AD&D policy. Many claims are denied because the claim handlers deem the death or injury to have occurred outside the scope of coverage. Always remember, the insurance industry is based on the premise that the companies are going to minimize payouts on claims whenever possible. Therefore, it is in their best financial interest to deny claims whenever possible. They will look for an opportunity to deny your claim. To best protect your claim, it is prudent to seek the counsel of an experienced AD&D attorney before filing your claim. Advocate Law Group’s experienced attorneys like Robert K. Scott, with more than 30 years of experience in the field and Gerry H. Goldsholle, with CEO-level insider knowledge of the insurance industry, can prepare your claim so that it will have a better chance of success.

Primary Reasons for Denial of a Claim

However, if your claim has already been denied, the insurance claims handler’s determination that your claim is not covered under an accidental death and dismemberment policy is by no means the final word. Claims are most frequently denied for two main reasons. Claims are denied because the cause of the accident is excluded from coverage under the policy. Also, claims are denied because the insurance handler has determined that the cause of the accident does not fall within the definition of “accidental” as stated in the terms of the policy.

Exclusionary terms are specific event or causes of injury or death that are expressly listed in the policy as being outside of coverage. The most common of these exclusionary terms are:

  • Suicide or attempted suicide
  • Drug use
  • Driving a vehicle while intoxicated
  • Injury or death sustained while intoxicated
  • Death during surgery
  • Physical or mental illness
  • War
  • High risk activities, such as sky diving

Claim handlers will make every effort to find that your claim falls within one of these specifically stated areas outside of coverage. For instance, when the insured dies in a car accident, the claim handler may find the cause of the car accident was suicide rather than an accidental cause that would be covered under the policy in order to avoid paying out the benefits deserved. Advocate Law Group has over 30 years of experience dealing with insurance companies and AD&D policies. They know the games that insurance companies play to avoid paying benefits. After you or your loved one is severely injured or killed, you don’t have time for games, it is time for results. Advocate Law Group knows how to get your claim paid.

The Definition of “Accidental”

Different policies contain different terms and definitions of those terms. What qualifies as “accidental” under an AD&D policy will depend on the specific terms of that policy. An experience AD&D attorney can review your policy and potentially appeal a denial of coverage based on the cause of the injury or death and the definition of accidental.Â

There are two main definitions of “accidental” as defined in the terms of most policies.

The “accidental” nature of an injury or death is determined under either an accidental means or an accidental result standard. Under an accidental means definition, the injury or death is not necessarily covered simply because death occurred accidentally. The accidental means standard requires that the cause or circumstances giving raise to the injury or death must not be voluntarily or intentionally created. Under this definition, any death that occurs as the result of a circumstance of the insured’s own creation is not an accident and is therefore not covered under the policy. The accidental means standard is a very limited and narrowly construed definition of “accidental” which results in many claims being denied.

Conversely, the accidental result standard is broadly inclusive of any cause or circumstance that resulted in death or injury occurring accidentally, even if the cause of the death or injury was of the insured’s own making. Even in such cases where injury or death is the result of the insured’s own conscious undertaking of a dangerous activity, the death or injury is said to be an accident because it was not the purpose of the insured’s actions. Depending on the terms your policy and the jurisdiction that governs the case, such a difference in policy terms can result in greatly different outcomes. AD&D claims are complex and require a specialized review in order to provide top-level representation.

Accidents That Occur Outside the US

This issue of what is an “accidental” injury or death is further complicated when the injury or death occurred outside of the United States. In less medically advanced countries, Medical Examiners will find a cause of death and produce a death certificate that may not comport with the quality of medical services expected by the insurance companies. Because of this, they will attempt to deny coverage. When you pay your premiums for an AD&D policy, the country in which you are injured or die does not matter. You and your family deserve those benefits. Advocate Law Group fights for the benefits you are entitled to under your policy.



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