Bay Area Accidental Death and Dismemberment (AD&D) Claims

Roberts Disability Law, P.C. represents beneficiaries or survivors against insurance companies who have denied their claims for accidental death and dismemberment benefits (“AD&D”). Our attorneys are knowledgeable about AD&D policies that the Employee Retirement Income Security Act of 1974 (“ERISA”) governs. ERISA typically covers accidental death and dismemberment benefit policies offered through an employer’s benefit plan.

What Should You Know About Your AD&D Policy?

Most employer-sponsored accidental death & dismemberment plans are “preempted” by ERISA. To be preempted by ERISA means that ERISA law, rather than state contract or bad faith law, will provide the rights and remedies available to you. If ERISA governs your AD&D policy and a dispute arises, a reviewing court will take into consideration an insurance company’s financial conflict of interest (for being both the decider and payor of benefits).

Some AD&D plans require notice of the claim within a certain period. But, if the AD&D plan is funded by an insurance policy, applicable state insurance law may have a “notice-prejudice rule” that will apply to your ERISA claim. In these circumstances, an insurance company cannot deny the claim for being late. But, be careful. If an AD&D policy also contains a deadline to file a lawsuit, then the claim may be time-barred nevertheless. ERISA law is complicated, but an experienced attorney will be able to help you navigate your claim.

Did you know? Long term disability claimants are frequently eligible for a waiver of the life insurance premium for their life and AD&D policies. It is important to obtain and review the applicable documents to see if this benefit is available.

In the case of plans providing for benefits in the event of accidental death or injury, a frequently litigated issue is whether the death or injury is the result of an “accident.” What is an “accident” is very fact-specific. In Tyler v. AIG Life Insurance Co., the Eleventh Circuit addressed the question of how “accident” should be defined in the absence of a definition in the policy and concluded that the court should look to analogous state law.

What Issues Are Common to AD&D Claims?

For AD&D claims, a common question is whether a prior medical condition caused the death, rather than a death caused by an accident. Courts have come up with tests for determining if preexisting conditions contributed to the death. The Ninth Circuit Court of Appeals (which covers California) has adopted a “substantially contributed” test to determine if a policy exclusion applies. In other words, a court will not consider a preexisting condition to be a cause unless it substantially contributed to the injury or death. Common exclusions include:

• Suicide. Was the death a result of suicide or an accident? Related questions include: Did the decedent expect to die as a result of her conduct? Would a reasonable person have viewed the injury as highly likely to occur as the result of the insured’s intentional conduct?
• Intoxication. Under the policy, did the death while driving under the influence constitute an exclusion based on self-inflicted rather than accidental injury?
• Course of Employment. Some plans provide for the payment of benefits only in the case of accidents arising out of the course of employment.
• Medical Risk. Does the death resulting from medical malpractice or known risks of medical procedures constitute an accidental death?

How Can Roberts Disability Law, P.C. Get Your AD&D Claim Paid?

The attorneys of Roberts Disability Law, P.C. work with various types of beneficiaries to appeal an AD&D claim denial, and when necessary, litigate these claims in court. Insurance companies may try to mischaracterize the cause of death or dismemberment or even misconstrue the terms of the AD&D policy. We assist you in all aspects of your claim and appeal by:

• Giving you the proper assistance and advice when filing the accidental death and dismemberment claim;
• Investigating the accident scene or death while working closely with trained experts;
• Examining your AD&D insurance policy and the applicable law;
• Preparing your AD&D claim and representing you through an appeals process if the insurance company denies your claim; and
• Advocating on your behalf in federal district court, and if appropriate, taking your case to the U.S. Courts of Appeals

If you get an AD&D claim denial, do not give up before consulting with one of our knowledgeable ERISA attorneys about your legal rights and options.