If an insured member of your family dies accidentally and you make an accidental death insurance claim as a beneficiary, the insurance company may require proof that the death was accidental before paying the claim. If that happens, you should immediately consult with a California insurance claims attorney.

Accidental death and dismemberment (AD&D or accidental death) coverage may be purchased as a stand-alone policy or as a rider to a life insurance policy (although usually, you must specifically request accidental death coverage when you purchase the policy). These policies are often issued through employers, typically as a group policy.

In our practice, we get the following questions: “Should I have accidental death and dismemberment coverage?” “How is accidental death defined by most life insurance companies?” “How does coverage for accidental death insurance work?”

Keep reading for the answers you may need about accidental death and dismemberment coverage and claims, and you will also learn what steps to take – and where to get help – if an insurer denies your accidental death claim.

How Does AD&D Coverage Work?

Accidental deaths happen in every imaginable scenario, but most are caused by car and bike accidents, falling down stairs or in the home, or similar kinds of occurrences.

Most life insurance policies cover accidental deaths along with deaths from natural causes. But accidental death coverage offers additional advantages to a beneficiary when an insured’s death is accidental because it will typically pay a large death benefit if a death was caused by an accident and it was not caused or contributed to by another cause, such as a medical condition, alcohol, drugs, etc.

Suppose a life insurance policy provides $250,000 of coverage, and you add an accidental death and dismemberment rider that pays a $500,000 benefit for accidental death. If the insured’s death is the result of a heart attack, stroke, or COVID-19, for example, the beneficiary will receive only the $250,000 payout.

Because such a death is deemed “natural” and does not meet the definition of an “accident,” the company will not pay the $500,000 accidental death benefit. However, suppose that the insured suffers a heart attack while driving and runs into a tree, resulting in death. Depending on the policy language and the jurisdiction you are in, such a claim may or may not be covered.

What Is an Accidental Death?

An accidental death is an unnatural death caused by an unintentional and/or unforeseen event, such as a slip and fall, traffic collision, or accidental overdose prescription medication or poisoning. Accidental deaths are distinguished from death by natural causes and from intentional homicides and suicide.

Life insurance companies define accidental death very narrowly. Accidental death insurance does not cover death resulting solely from illness or other natural causes. But some policies cover deaths that result partially from illness or natural causes, if the death was caused by an accident in some manner. Most accidental death policies place considerable limits on what types of accidents are covered.

Some accidental death policies do not cover deaths where the decedent was intoxicated at the time of death, the decedent’s own gross negligence caused death, or the death was caused in whole or part by a medical condition or treatment, even if a medical examiner, a coroner, or a police officer determined the death to be accidental.

For example, if the decedent had a stroke while driving and died in a traffic accident, the life insurance company may deny an accidental death claim by determining that the stroke, rather than the traffic collision, was the cause of or contributing factor in death.

Accidental death and dismemberment coverage also usually excludes suicide, war, criminal activities, and professional athletic injuries. Any dangerous activity, such as auto racing or skydiving, may also be excluded.

How Are Accidental Deaths Investigated?

When an accidental death claim is filed, the life insurance company’s claims department opens an investigation. The insurer typically reviews the death certificate, any medical examiners or coroner’s reports, accident/police reports, and the decedent’s health records.

While a coroner’s report or death certificate may describe a car accident or slip-and-fall fatality as accidental, this is not binding on the insurer, which may determine that the accidental death policy does not cover the death because the coroner’s report or death certificate may also mention that a medical condition also contributed to the accident. The denial of an accidental death claim is often linked to a decedent’s pre-existing medical condition.

What Can You Do If Your AD&D Claim Is Denied?

It may be impossible to prove whether a past event, a pre-existing medical condition, or an accident itself caused death. Many life insurance companies exploit that impossibility to deny accidental death benefit claims. If a life insurance company rejects your accidental death claim, schedule a consultation with a California accidental death claims attorney to discuss your rights and options.

Insurance companies commonly deny accidental death claims by taking the position that there is inadequate evidence that a decedent’s death was “accidental.” A good and experienced California accidental death claims lawyer will obtain witness statements, hire necessary experts, conduct appropriate legal research, review the evidence, and either present a well-prepared appeal to the insurer or file a lawsuit against the insurer.

How Will Your Case Be Handled?

If the accidental death coverage was purchased directly from a life insurance company without employer involvement, and your accidental death claim is denied, the state law in the governing jurisdiction will control what law applies to the accidental death claim, and will be important if you decide to sue the insurance company.

However, if the accidental death coverage was obtained through an employer, it is likely governed by the Employee Retirement Income Security Act of 1974 (ERISA), and you will be required to pursue an administrative appeal before suing the insurance company.

If that administrative appeal fails, a California accidental death claims attorney will file your lawsuit in the United States District Court, as the federal courts have jurisdiction in most cases that involve an employer-sponsored insurance plan.

At your administrative appeal or in a federal or state court, the right California accidental death claims lawyer will present the best possible evidence that the death was in fact accidental, and that the beneficiary is therefore entitled to the full accidental death payout.

How Can the Right Attorney Help You?

Even before submitting an accidental death claim to an insurance company, an California accidental death claims attorney can help you. Let an experienced attorney conduct an investigation as discussed above and prepare your claim or appeal of a denial of a claim to submit to the insurance company.

When your claims attorney prepares an accidental death claim, he can investigate the facts surrounding the decedent’s death, anticipate the reasons the insurance company may deny the claim, and address those reasons, all before submitting the appeal. If the appeal is not needed or if it is denied, an experienced accidental death insurance lawyer will file a lawsuit on your behalf.

How Are Most Insurance Claim Disputes Resolved?

The right accidental death claims lawyer can show the insurance company that the claim has merit and possibly negotiate an acceptable out-of-court settlement for you without having to go through a stressful trial.

Most insurance disputes in California are resolved outside of court, but if no reasonable settlement is possible, your lawyer can take your claim to an administrative appeal or to trial.

The accidental death of a loved one is always difficult. Even so, if your accidental death claim is denied, you should reach out immediately to a California AD&D attorney who will aggressively fight the insurance company on your behalf. Choosing the right attorneys, such as McKennon Law Group PC, can make all the difference in the outcome of your AD&D case.