If the insurance policy does not define “accidental” or “accident” then one must look to the “reasonable expectations” of the insured. The Federal Court in the Ninth Circuit has defined “accident” as an unintended and unexpected event. The test the Ninth Circuit has set forth to determine if an event was unintended and unexpected is to determine whether a reasonable person with a similar background as the insured would have viewed the resulting death as substantially certain to result from the insured’s conduct. If so, then the death is not accidental.
Yes, if the overdose is from a prescription drug (in most states, including California). If the overdose drug is not prescribed by a physician, then it would depend on whether there is an exclusion in the policy for death resulting from the use of intoxicants. One must always look at the policy to determine what coverages and exclusions it contains. Click here to view specific examples.
My husband died after falling and breaking his hip. He had a lot of medical problems, but the medical examiner said if not for the accident he would still be with us. But the insurance company denied my claim for accidental death benefits.
First, you should be aware that insurance companies deny valid claims regularly. So do not be discouraged from seeking help from any attorney to pursue your claim. I have seen many cases where accident death claims are denied when the death results from a fall because the insurer claims that either the fall was caused by an illness or the illness contributed to the subsequent death.
Determining that the death was accidental is an important factor, but does not guarantee that your claim will be paid. Most policies have exclusions when an illness contributes to the death. These are tricky cases and you need the help of an experienced attorney.
The answer depends on 1) the terms of the policy, 2) the facts leading to death, and 3) the applicable law. Many courts have found that the unexpected death due to medical malpractice is considered and “accidental death” under an accidental death policy. But many policies now exclude death “caused or contributed to by” an illness or the treatment thereof which may exclude these types of claims. However if the insured is injured and then dies due to the malpractice of the physicians treating the injury then there likely will be coverage.
These types of cases are complex and require the review by an attorney experienced in handling claims under an accidental death and disability policy.
Long Term Disability Benefits are wage replacement benefits, that is, they are paid to an individual in the event of a sickness or injury resulting in an inability to work. Typically these benefits are calculated based on a percentage of your gross income.
If the LTD policy is purchased by the employer as an employee benefit, then more than likely, the claim will be governed by ERISA. ERISA is an acronym for Employee Income Retirement Security Act of 1974 which was enacted to regulate and protect employee rights. If an LTD policy is governed by ERISA then State law remedies which normally apply to an improper denial of insurance benefits do not apply.
Yes, if you work for a governmental entity, they will have their own disability retirement plan and their own rules and procedures for filing for disability benefits. As opposed to an administrative appeal under ERISA, most governmental plans provide that if the application for benefits is initially denied, the employee is entitled to a judicial hearing or de novo hearing at which the employee can present evidence of their disability. If you are required to go through an evidentiary hearing, you should seek legal counsel for help. To view a claim against the County of San Diego handled by Stennett & Casino click here.
Under ERISA regulations the denial letter you receive will include the specific reason for the denial, it will reference the specific provisions in the policy on which the adverse determination was made and it should describe what additional material is necessary to perfect the claim. It will also delineate the time period in which an appeal must be filed, where to file it and will offer to provide you with a complete copy of the claims record at no cost to you. This is usually the time to make first contact with an experienced ERISA attorney to help in planning the appeal.
Typically the next step is to file an action for wrongful denial of benefits in Federal Court since they have jurisdiction to hear these matters. You need to consult with an experienced ERISA attorney.
Administrative Record is basically the claims file consisting of all the papers and evidence relied upon to either approve or deny the claim.
De Novo Standard of Review means that once suit is filed the judge determines if you are entitled to benefits without giving any deference to the decision of the insurance company.
Arbitrary and Capricious Standard of Review means the judge will give deference to the decision of the insurance company and will only overturn their decision if he determines that the insurance company abused its discretion.
Own Occupation is important since most LTD policies initially determine disability based upon the physical requirements of your own occupation. It is important that your employer submit to the insurance company an accurate description of your job and not a generalized “watered down” description of what you do.
Any Occupation most LTD policies after a specified period of time will determine disability based on your ability to perform the physical requirements of “any occupation”. However, the occupation must be one in which you could reasonably engage based upon your education, training and experience
If you have a group policy it is most likely covered by the federal law known as ERISA (Employee Retirement Income Security Act) and you need an attorney specializing in ERISA claims. If it is an individual policy that you purchased then it most likely is covered by California State insurance law. In that case you need an attorney experienced in civil litigation and insurance disability claims (as opposed to social security disability and workers’ comp claims). There are several attorneys locally that deal with insurance disability claims, but very few that deal with ERISA claims. Our firm handles both.
LTD policies often have provisions allowing the insurer to offset “other benefits” such as Social Security Disability. If you are not receiving Social Security benefits the insurer often requires you to (1) apply for Social Security benefits through the appeals process and (2) agree to reimburse the insurer any retroactive benefits you receive from Social Security. If you do not sign such an agreement they will often deduct an estimated amount you will receive from Social Security from your LTD benefits.
An insurer may attempt to rescind a life insurance policy retroactively if the death occurred within the first two years of the policy issuance. However, the insurance company can rescind a policy only when the insured made a material misrepresentation in the original application for insurance.
Term Life is a policy that provides life insurance protection for a specified term or period of time – typically from 1 to 30 years or until a specified age. Term life insurance provides a death benefit only with no build up of cash value. Thus, term insurance is the least expensive and most straight forward of all life insurance policies.
Whole Life Insurance is a policy that provides life insurance protection throughout the life of the insured as long as the premium is paid when due. The premium may be level or increase after a fixed period, but it will not change from the premium schedule provided when the policy was purchased. Part of each premium payment is applied to the policy’s cash value account, which grows on a tax deferred basis. In addition to providing guaranteed premiums, death benefits and cash value, whole life policies may also pay policy dividends in some cases. As a result of these additional benefits whole life policies are substantially more expensive than term life policies.
Universal Life Insurance is a policy that provides life insurance very similar to whole life policies with the exception that there is flexibility with regard to the premium and amount of insurance provided, allowing the insured to change these amounts within certain guidelines. Because of this fact the policy may not be permanent if the policyholder under-funds the policy by not paying full premiums.
Yes, but you must look closely at the terms of your policy. There are strict time limitations for converting your group policy to an individual policy. But, if you left employment because of a disability you may be able to retain your life insurance without having to pay ongoing premiums because of your disability.