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.
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