Accidental Death & Dismemberment Insurance – Frequently Asked Questions

When making an accidental death or accidental dismemberment insurance policy claim, it is important to clarify whether the insured has an individually-purchased policy or an employment-based group policy. If the insured is a member of a non-governmental employment-based group life insurance plan, the life insurance will be governed by a federal law called the Employee Retirement Income Security Act of 1974 or ERISA, which establishes the standards for the parties responsible for administering an ERISA plan and claim and has stringent requirements for processing an accidental death or accidental dismemberment insurance claims. If the insured owns an individual an accidental death and accidental dismemberment insurance policy, any required deadlines and standards in processing an accidental death or accidental dismemberment insurance claim will be administered according to state law. As discussed in this FAQs section and as discussed in the insurance bad faith and ERISA FAQs sections, it is critical to determine whether ERISA or state law apply as the available remedies and potential damages are very different.

In making an accidental death or accidental dismemberment insurance claim, the insured will first want to clarify whether he/she has an individually-purchased policy or an employment-based group plan. If the insured has a non-governmental employment-based group policy, the plan will be governed by a federal law called the Employee Retirement Income Security Act of 1974 or ERISA, which sets the standards for the party responsible for administering an ERISA plan. ERISA has stringent requirements for processing life insurance benefit claims. If the insured owns an individual life insurance policy, any required deadlines and standards in processing an accidental death or accidental dismemberment insurance claim will be administered according to state law. California law is particularly beneficial to life insurance claimants.

General Timeline For ERISA Governed Accidental Death & Dismemberment Insurance Policies Under Group Plans

• A claim should be approved or denied within 90 days of receipt of the claim. See 29 C.F.R. § 2560.503-1 (f)(1).
• Should more time be necessary to review a claim, the plan can extend the time frame for up to 90 days, but the plan must inform the insured within the initial 90 days that additional time is needed, why the additional time is needed, if there are any unresolved issues or additional information needed, and when a final decision will be rendered. Id.
• If a claim is denied, the insured has 60 days to file an appeal. See 29 C.F.R.§ 2560.503-1 (h)(2) (i).
• A decision on the insured’s appeal must be made not later than 60 days after receipt of the insured’s request to review a denied claim. See 29 C.F.R. § 2560.503-1 (i)(1).
• Should special circumstances require an extension, the plan may take up to 60 extra days, but the plan must provide an explanation in writing of the special circumstances along with providing a date by which the plan expects to make a decision on the insured’s claim. See 29 C.F.R. § 2560.503-1 (i)(1).

General Timeline For Individual Policies Governed By California Law

• A claim should be approved or denied within 40 calendar days of receipt of all necessary information to determine liability for the insured‘s claim. See 10 C.C.R. § 2695.7 (b).
• The 40-day period does not begin to run until all relevant information has been received. See 10 C.C.R. § 2695.7(b).
• Should the insurer require additional information to conclude the claim investigation, then it must notify the insured in writing within 40 days after the claim is filed, and provide a written list of all information reasonably needed to investigate the claim. See 10 C.C.R. § 2695.7 (c) (1).
• An insurer must continue to send the insured an update every 30 days if additional time and materials are still required, while continuing to clearly set forth what is needed to process the claim. See 10 C.C.R. § 2695.7 (c) (1).
• California law provides four years to sue on a contract. See CCP. §337 (1). However, an insurance contract may set forth a shorter time limit in which a suit must be brought in the policy, if the policy provision is clearly stated and reasonable in the time it provides. See Frazier v. Metropolitan Life Ins. Co., 169 Cal.App.3d 90, 103 (1985) (Two year statute of limitations was found to be reasonable).

Call your insurer or go online to ascertain how you begin the process of filing an accidental death or dismemberment insurance claim. Aside from the actual claim form, the most important document in filing an accidental death or accidental dismemberment insurance claim is the insurance policy, or if the insured is a member of a group insurance program for which ERISA applies, the summary plan description and group insurance certificate. These documents typically provide a detailed overview of how the plan or policy works, what benefits it provides, what exclusions apply and how to file a claim for benefits. If the insured is a member of a union or a plan associated with a collective bargaining agreement, he/she should also check any applicable collective bargaining agreement’s procedures for filing, claims, grievances and appeals. If the insured does not have a copy of the insurance policy or summary plan description, the insured should immediately make a written request for a copy of his/her policy, summary plan description and/or group certificate that contains the claims procedures. The plan administrator in ERISA matters is required by law to provide the insured with a copy upon written request. The insured will also want to contact his/her insurance agent, insurer or plan administrator to obtain claim forms.

At the very minimum, an insurer will require that the insured provide the death certificate of the insured person and an accident report if one exists. In some situations, a copy of a marriage certificate may also be helpful, particularly if there are ex-spouses that use names from former marriages. An owner or beneficiary may also need to have access to current mortgage or loan paperwork, credit card statements and employee benefits information.

Remember, an accidental death or accidental dismemberment insurance claim is a very proof intensive process in which you must be able to prove that the primary or substantial cause of the death or dismemberment was an accident or accidental bodily injury. A claimant should document all interactions with insurer, plan administrators, employers and representatives of the insurance company (such as insurance agents) every step of the way. Always memorialize all telephone or in-person conversations by letter summarizing what was discussed, and send it to all parties involved in the processing of the claim to confirm the communication occurred. Also, the claimant should maintain a file of everything related to the claim and keep a chronology of claim related events. This way, should the insured be forced into litigation, there is a clear and definitive record of how the claim was handled.

The most common exclusions in these insurance policies state they do not cover a death or dismemberment that was caused in whole or in part by medical conditions. Similarly, most policies state they do not provide coverage for any death that was caused in whole or in part by a non-accidental event. Accidental death and dismemberment insurance policies also typically contain provisions excluding coverage for death caused by suicide or attempted suicide. Policy language excluding suicide must be plain and clear and conspicuous to be enforceable. This requires that the words used in the policy are part of the working vocabulary of the average layperson, and that the policy exclusion is presented or positioned in a place that attracts the reader’s attention. See Malcolm v. Farmers New World Life Ins. Co., Cal. App. 4th 296, 301-302(1992). For example, California courts have held that the phrase “suicide, whether sane or insane” was not ambiguous, and was easily understood as intentional self-destruction independent of whether the insured was sane or insane at the time of the act. See Searle v. Allstate Life Ins. Co., 38 Cal.3d 425, 436 (1985). While a death that occurs during an attempted suicide will result in an exclusion of policy benefits, a death resulting from an “accident” is not a “suicide’ even if the decedent was engaged in reckless activity.” See Padfield v. AIG Life Ins. Co., 290 F.3d 1121, 1126(9th Cir. 2002) (applying federal common law under ERISA). The insurer must establish beyond a preponderance of the evidence that the insured took his or her life, and while evidence of mental impairment is admissible, it will not necessarily be the determinative factor in a finding of suicide. In order for mental capacity to be the determinative factor, it must be established that the mental capacity of the insured was so impaired that he or she did not understand the physical nature and fatal consequences of the act that was the cause of death. See Searle v. Allstate Life Ins. Co., 38 Cal. 3d at 439 (1985).

Criminal or intentional acts exclusions are also common exclusions, and typically exclude coverage for injury or death sustained while committing or attempting to commit a felony. See Romero v. Volunteer State Life Ins. Co., 10 Cal.3d 571, 574 (1970). Some other insurance exclusions include dangerous act exclusion, war time exclusion and aviation exclusion. These exclusions are becoming rarer as most insurers tend to charge a higher premium to cover these activities rather than exclude them as they did in the past.

Insurers most commonly deny accidental death or dismemberment claims by asserting that there is insufficient evidence to support the claim or by asserting that the death or dismemberment was not caused primarily or exclusively by an accident or accidental event. They will also assert that certain exclusions apply, such as the death was a suicide, that the death was caused in whole or in part by an existing medical condition or took place while the insured was committing a crime or engaged in illegal conduct. You need an experienced attorney who will help you fight back against these insurance companies by making sure you have adequate evidence to support your claim, that you have the correct law and that you have the right experts assisting you. For a claim to be successful, it is important you work with an attorney that has a history of litigation success.

Immediately contact an experienced lawyer who can aggressively litigate your accidental death case to achieve the compensation you deserve. If your accidental death or dismemberment insurance claim was denied, do not panic. The right attorney will help you file an appeal of this denial or will file an appropriate lawsuit to recover your denied benefits, in addition to attorneys’ fees, emotional distress damages, economic damages and possibly punitive damages.

Choosing the right attorney is not easy, but a skilled litigator with decades of experience resolving bad faith and ERISA insurance claim disputes for individuals and their loved ones will drastically increase your chances of a positive outcome and is worth the time it takes to track down the best accidental death insurance lawyer you can find.

Our team of renowned attorneys has contested and been consulted on thousands of ERISA, disability insurance, life insurance, accidental death and dismemberment insurance, health insurance, bad faith, and other insurance matters. We are proud to advocate on behalf of California residents and their loved ones and we are also proud to advocate on behalf of residents nationwide. We use our thorough knowledge of ERISA and California and other state law to advocate for you in court or on your appeal and to ensure you are being accurately represented. If you or your loved one is a victim of an accidental death or a dismemberment, you and they deserve to be compensated adequately.