May 10th, 2016

We are seeing more and more claims for Accidental Death benefits denied under an exclusion for “loss” caused by “illness or the treatment thereof.” Whenever an insured involved in an accident is taking prescription medication, the insurer argues that the accident was, in part, caused by the medication side effects. Likewise, when an insured has an illness that weakens his/her ability to recover from a physical trauma, the insurer argues that the illness contributes to the death and thus is excluded under the policy.

 

These arguments taken to their extreme would result in almost all Accidental Death Claims being denied unless the insured was in absolutely perfect health at the time of his/her accidental death. Stennett & Casino have been able to overcome these defenses in multiple ways depending on the specific facts and policy involved.

 

As an example we recently had a young woman contact us whose husband died after falling in the kitchen and hitting his head resulting in a skull fracture and subdural hematoma. MetLife denied her claim for Accidental Death benefits under the “illness exclusion” because the death certificate indicated that a contributing cause of death was a “seizure disorder.” The claim was that her husband fell because of a seizure. However, a close review of the medical records reflected that her husband did not suffer from a seizure disorder but rather experienced a seizure after hitting his head. Additionally, even if his fall had been caused by a seizure, the seizure was not the cause of death. The cause of death was the skull fracture and subdural hematoma.

 

Stennett & Casino convinced MetLife to pay the full amount of policy benefits plus interest without having to file suit.

 

May 6th, 2016

Our client was a 64 year old second grade bi-lingual teacher who fell hitting her forehead into a concrete wall. She immediately lost consciousness but believed she was okay.  Over the next several days her family noticed that she was incoherent so she did not return to work but had a substitute teacher cover her classes.

She filed a claim for disability benefits with Standard Insurance Company. They paid her benefits for a year and a half when her benefirs were terminated.  She hired Stennett & Casino to handle her appeal.

It was obvious to us that our client suffered a traumatic brain injury. In order to prove her disability we had her undergo neuropsychological testing. The testing supported her injury.

Stennett & Casino submitted the testing as part of her appeal.  As a result Standard Insurance reopened her claim and paid the benefits owed her under her disability policy.

May 6th, 2016

Our client’s daughter died while she was an inpatient at a drug rehabilitation center due to the toxic effect of combining prescriptions for an anti-depressant with methadone which were both administered by the facility. The treating physicians should never have combined these 2 medications since they have a known toxic reaction.

The father’s claim for benefits under his accidental death policy with Life Insurance Company of North America (LINA) however was denied under an exclusion for death resulting from an illness or the treatment thereof. The father lived in Palmdale California and found the Law Offices of Stennett & Casino through a web search. Since we had handled several cases with similar issues he felt we were the right fit for his claim against the insurance carrier.

After filing an administrative appeal on the father’s behalf and then filing suit in the Los Angeles Federal District Court LINA (a subsidiary of CIGNA) continued to deny coverage. It wasn’t until Stennett & Casino filed a motion for judgment asking the court to confirm our interpretation of the policy that the insurer finally relented and paid under the policy.

May 6th, 2016

Our client’s wife had been prescribed narcotic pain medication for several years due to extreme back pain. Tragically her pain became so severe that she accidentally overdosed on her medication. Our client made a claim with Prudential Ins. Co. under his Accidental Death & Disability policy. Prudential denied his claim under an exclusions for death caused by illness or the treatment thereof.

Our client lived in San Bernardino County and found the Law Offices of Stennett & Casino through our webpage and noticed that we had handled many similar cases.  After retaining Stennett & Casino Prudential continued to deny the claim.  However after filing suit in Riverside Federal District Court and pointing out how Prudential’s policy contradicted itself by both providing coverage for death resulting from prescription medication and then excluding the same cause of death, Prudential paid the full policy benefits.

May 5th, 2015

Accidental Death and Disability (AD&D) policies cover loss caused by “accident.” Accident is generally defined by the courts as an “unexpected and unintended” occurrence. Thus though injury from a medical procedure may be part of the normal risk of the procedure (and thus not unexpected) injury due to the negligence of the doctor is never expected or intended and thus is classified as an accident.

Nevertheless insurance companies typically deny claims for AD&D benefits arising out of medical malpractice. This is often due to an exclusion in most policies for loss caused by sickness or the treatment thereof. However, depending on the actual policy language and the specific facts of the case, we have been able to obtain coverage despite the medical treatment exclusion. As an example we have had several cases where death was caused by the toxic interaction of medication prescribed by a physician or where the amount of a single medication prescribed became fatally toxic.

The California Insurance Code limits the manner in which insurance companies can exclude losses caused by prescription medication.  Insurance policies that are written for distribution throughout the country often fail to comply with individual state’s requirements.  Additionally at times the policies themselves become ambiguous when they specifically indicate they cover certain losses but then turn around in a later section and claim that they exclude the same losses. Since the insurance company created the policy any ambiguities in the policy must be interpreted in favor of coverage.

The bottom line is that if you believe you may have a claim under an AD&D policy do not be satisfied with the explanation of an insurance company when they deny your claim. Seek out an attorney experienced in life and AD&D insurance to provide you their perspective. These evaluations are, at no charge to the client.  Therefore, you have nothing to lose.

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