Stennett & Casino

Who Has The Burden of Proof In An Insurance Claim

Whether you make a claim for benefits under an Accidental Death Policy or a Disability Policy the same burden of proof rules apply. The claimant has the burden of proving that they qualify for policy benefits (that they are disabled in a disability policy claim or that the death was accidental in an accidental death policy claim). However, the insurer has the burden of proving that any claimed exclusion in the policy applies to defeat coverage. As an example, in an accidental death claim the claimant must prove that the death resulted from an “accident” but the insurer who denies a claim because of an exclusion in the policy such as for death caused or contributed to by the intoxication of the insured must prove that the decedent was intoxicated and that their intoxication was a cause of death.

The more difficult question is who has the burden of proving whether a limitation in the policy applies or does not apply. As an example, the typical disability policy limits the payment of benefits to 24 months for disabilities caused by mental illness. The courts are split on who has the burden of proving whether a limitation applies such as the mental illness limitation.

As stated in Kamerer v. Unum Life Ins. Co. of Am. (D.Mass. 2018) 334 F. Supp. 3d 411, 427-428:

Some courts have held that the claimant bears the burden of showing the limitation does not apply. In Hoffmann v. Life Insurance Company of North America, for example, the court held that a mental illness limitation was not an exclusion under the policy, and therefore, the plaintiff bore the burden of proving the limitation did not apply. 2014 U.S. Dist. LEXIS 177956, 2014 WL 7525482, at *5-6 (C.D. Cal. 2014). On the other hand, some courts have found that the insurer bears the burden of proof. For instance, in Okuno v. Reliance Standard Life Ins. Co., the Sixth Circuit held that the insurer “bears the burden to show that the exclusion on which it based denial of benefits, the Mental and Nervous Disorder Limitation, applies in this case.” 836 F.3d 600, 609 (6th Cir. 2016).

This very issue came up in one of Stennett & Casino’s cases but the court sidestepped the issue finding for our client regardless of who had the burden of proof. (See Jarillo v. Reliance Std. Life Ins. Co., 2017 U.S. Dist. LEXIS 59928).  But the issue may be important in certain cases. How the court decides that issue may depend on specific circumstances in the case and where the case is filed.

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