Accidental Death Insurance Claims Success Stories

MetLife Denies Accidental Death Benefits Under Exclusion For Death Caused Or Contributed To By Illness Or Sickness.

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.

 

Death Due to Toxic Drug Interaction and Medical Malpractice

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.

Death Due to Accidental Overdose of Pain Medication

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.

AD&D Policy Covers Death Caused By Medical Malpractice

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.

A Tale of Two Life Insurance Companies – One (LINCOLN NATIONAL) Pays Accidental Death Benefits And One (CIGNA) Denies Benefits

Our Client’s Husband, who had a history of alcohol issues, died following an evening of binge drinking.  The coroner’s office classified the manner of death as “accidental” and the cause of death as “acute alcohol intoxication.”  The Husband had two insurance policies that promised benefits to his wife if he died as a result of an accident. Our client submitted a claim to each of the insurance companies and both denied coverage under an exclusion for loss caused by “sickness or disease.”  Both insurance companies claimed that a contributing factor to decedent’s death was his alcoholism which they asserted excluded coverage.

After obtaining clarification from the San Diego County Medical Examiner that decedent’s death was due to “acute” alcohol intoxication and not from his “chronic” alcoholism (which can cause serious medical issues like liver disease), we submitted an appeal to both insurers on behalf of our client.  One insurer, LINCOLN NATIONAL, responded by paying the accidental death benefits.  The second insurer, CIGNA, responded by reiterating its denial by asserting that decedent drank the amount of alcohol that resulted in this death because “alcoholics can’t stop drinking.”

With the assistance of our own medical consultant, we pointed out the absurdity of CIGNA’s position.  To suggest that an alcoholic cannot stop drinking because of his “alcoholism” would mean that every alcoholic would die at a very young age due to their inability to stop drinking.  This of course is not the case.  There are numerous reasons why an individual may drink to excess on a particular occasion.  None of these potential causes were investigated by CIGNA.  CIGNA just assumed that his drinking problem caused him to drink, on this one particular day, more than his body could handle.

Both insurance carriers initially denied the claim.  After submitting an appeal, LINCOLN looked at the evidence and concluded that the claim was covered.  CIGNA, on the other hand, ignored the evidence and looked for excuses to deny the claim.  This has resulted in a lawsuit against CIGNA, which we believe will result in payment of the claim.

Denials of Accidental Death claims, due to the standard exclusion for death caused by “sickness or disease or the treatment thereof” are often improper.  If you find yourself in the unfortunate situation of our client in this case, make sure to consult with an experienced attorney to help you with your claim.

UNUM Denies Accidental Death Benefits Due to Poor Health of Insured

Our client’s husband died after falling and hitting his head on their back patio.  The trauma caused a subdural hematoma which became mortal in less than four hours.  The death certificate classified the death as “accidental.”  The “immediate cause” of death was listed as “subdural hemorrhaging from blunt force injury to head” and a “contributing condition” was listed as “thrombocytopenia.”

Client submitted a claim to UNUM Insurance Company for benefits under an accidental death policy.  UNUM denied the claim based on a limitation in the policy that excludes coverage for accidental losses “caused by, contributed to by,  or resulting from diseases of the body.”  The disease cited by UNUM was thrombocytopenia, which was most likely a consequence of decedent’s recent bone marrow transplant performed as treatment for his carcinoma.   Thrombocytopenia is a condition that results in excessive bleeding, which UNUM asserted substantially contributed to the subdural bleeding resulting in death.

Stennett & Casino obtained a statement from the medical examiner’s office that supported their client’s position.  In effect, the medical examiner stated that though decedent’s condition of thrombocytopenia may have contributed to the bleeding there was no evidence with which one could say that decedent would have survived the fall in the absence of the thrombocytopenia.  Despite this evidence UNUM continued its denials.  Stennett & Casino filed suit on behalf of their client which resulted in a settlement of the claim.

Accidental Death Claim: Intoxicants

The client’s husband died in an auto accident when a faulty gas tank ruptured and fire engulfed his car.  The insurance company refused to pay her the accidental death benefits because of an exclusion in the policy for losses occurring when one is driving while under the influence of an intoxicant.  Here, an autopsy found morphine in the deceased husband’s blood.

We investigated and found that the morphine was a byproduct of his pain medication (Tylenol with Codeine) prescribed for the husband for his back condition.  We pointed out to the insurance carrier the California Insurance Code prohibits an insurer from denying an accidental death claim based on the use of prescribed medications.  The insurer continued to deny the claim.  We filed an ERISA lawsuit on behalf of our client. 

Stennett & Casino took the case to trial and our client was awarded judgment for the entire amount of the policy plus interest and attorney’s fees.

Accidental Death Claim: Drug Overdose Death

Our client’s son died as a result of an accidental drug overdose.  The father was the beneficiary on the accidental death insurance policy.  Insurance company refused to pay the benefits claiming that the death was not “accidental.”  The question came down to whether it was reasonably foreseeable that one would die as a result of taking illegal drugs (in this case heroin).  The insurance company pointed to cases from other states that held that death due to overdose of cocaine was not “accidental.”  We found governmental statistics that indicated that the incidence of death by overdose among heroin addicts was .014%.  These statistics along with the facts that decedent was not a regular user and was scheduled the next day to fly to St. Louis to join his brother’s family and start a new life were instrumental in convincing the court that it was not reasonably foreseeable that decedent’s use of heroin would result in his death – thus, it was an “accidental death.”  Judgment was obtained against the life insurance company for the full amount of the death benefits plus interest and attorney’s fees.

Accidental Death Claim: Exclusion for Death Due to Treatment of a Disease

The 59-year-old mother of our client died of an accidental overdose of her pain medication, Oxycodone. The mother was insured with an accidental death policy; however, our client’s claim for benefits following her mother’s death was denied.

The insurance company denied the claim under the exclusion for losses caused by illness or the treatment thereof. It asserted that Oxycodone was a treatment for chronic pain and thus excluded by the policy provisions.

Stennett & Casino argued that California Insurance Code §10369.12 precluded an insurance company from excluding a loss caused by prescription drugs. The court agreed with our interpretation of the Code and held that the exclusion was void as it applied to our case. Our client thus received the full value of the insurance policy plus attorney’s fees.

Accidental Death Claim: Denied Because Insured was Drinking and Driving

An accidental death insurance policy will pay benefits when the insured dies as a result of an accident.  But when the insured dies in an auto accident with a high blood alcohol rate – is that an accident?  That was the issue in a recent case we handled in which our client’s husband died in a single car accident while driving home from his brother’s house after having a few beers.  The insurance company argued that since the husband had intentionally consumed alcohol and intentionally driven home knowing he was drunk and knowing the dangers of drinking and driving, that his resulting accident was not accidental.

Only an insurance company could argue that an accident was not an accident under their policy.  Though everyone knows what an accident is, it becomes mysterious when it comes up in court.  Unfortunately there are cases on both sides of this question.  However, we were able to argue common sense, the evidence of the case and the law to prevail for our client.

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