AD&D Claim Denied Due to a Sickness Exclusion

AD&D (accidental death and dismemberment) insurance provides coverage in cases of accidental death and dismemberment. In regard to death, AD&D is available only when the insured died as a result of an accident. an AD&D policy will not pay benefits for deaths due to natural causes (which are generally covered by regular life insurance).

Unfortunately, life insurance companies that sell both life insurance and AD&D coverage do not explain in detail the difference between the two types of policies and many policyowners do not know that their AD&D covers only accidental death.

It is important to read the whole policy carefully to understand its provisions and conditions before purchasing it.

An AD&D policy is accidental death insurance that covers accidental death and death due to accidental means. As any other insurance policy, an AD&D policy has many life insurance exclusions, or provisions which describe what deaths are not covered.

Every insurance company’s AD&D policy is different, but there are some commonalities of many AD&D contracts when it comes to exclusions. A sickness exclusion is one of the most popular exclusions that is found in almost any AD&D policy.

Sickness exclusions are provisions in the policy that exclude from coverage any death that was caused by, contributed to by, or resulted from, a sickness. A sickness exclusion may be interpreted broadly or narrowly, depending on who is reading the contract.

The problem with a sickness exclusion is that it can be misinterpreted and can exclude any death if an insured had any sickness at the time of his/her death.

For example, if an insured died in a car accident and the coroner’s report shows heart disease as one of the diagnoses of the insured, the insurance company can deny the AD&D claim for death benefits based on the sickness exclusion if it shows that the insured’s heart disease (sickness) somehow contributed to the accident.

In another example, if a person dies from anaphylactic shock, the insurance company may deny the beneficiary’s life insurance claim based on a sickness exclusion. The insurance company can deny the AD&D claim in such a case, because it can claim that a food allergy caused or contributed to the insured’s death.

Likewise, if an insured died as a result of medical malpractice, some life insurance companies may deny an AD&D claim claiming that a sickness exclusion applies. The insurer may argue that the decedent had a sickness for which he sought medical treatment and that he died as a result of treatment of that sickness, therefore, the insured’s sickness caused or contributed to his death and AD&D benefits are not available.

A sickness exclusion, if misinterpreted, can result in a wrongful AD&D claim denial.

The language of the policy is very important in considering whether an AD&D claim was incorrectly denied and whether the beneficiary has a right to recover AD&D benefits.

As a layperson, you may attach a different meaning to the exclusion due to sickness, because plain and ordinary meaning of the sickness exclusion language appears to state that only death due to natural causes is not covered. An AD&D attorney can help you dissect the language in your AD&D policy and explain to you what coverage it actually offers.

Call (888) 510-2212 for a free consultation.

Picture of About the author

About the author

Attorney Tatiana Kadetskaya has over 10 years of experience in life insurance law representing beneficiaries and policy owners. She is best known for successfully collecting denied and delayed claims and settling complex beneficiary disputes and interpleader lawsuits.

Contact us