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Getting Accidental Death & Accidental Dismemberment Payouts

What is an AD&D policy?

Typically accidental death and dismemberment insurance (AD&D) is available as a rider to a life insurance policy or a health insurance policy. An AD&D rider covers the unintentional dismemberment or death of the owner of the policy. It is also referred to as a “double indemnity rider.”

These are the common types of AD&D policies:

  • Group Life Rider. Usually provided by an employer, and the AD&D benefit commonly equals the death benefit. Sometimes coverage for dependents is also offered.
  • Voluntary AD&D. Offered by an employer as an elective benefit for which employees pay extra.
  • Travel Accident AD&D. Employers provide a supplemental benefit that covers employees while travelling on a business trip.

Many AD&D policies only cover accidents that occur off the job, not on the job.

How does AD&D insurance work?

In the case of an accidental death, designated beneficiaries can receive both the benefit from the life insurance policy and the benefit from the AD&D rider. It is common for the AD&D benefit to equal the amount of death benefit provided in the life insurance policy, and beneficiaries can receive both – thus the “double” in “double indemnity rider.” If the insured died due to injuries sustained accidentally, the death must have occurred within a specific time period following the injury to be covered by the AD&D rider. This time will vary among policies and may be governed by state law.

In the case of accidental dismemberment of the insured, as defined in the rider itself, the insured will receive a total or partial payout. The percentage of total benefit payout for specific injuries will be set forth in a “schedule” listing various injuries, as part of the rider.

AD&D coverage commonly ends when the owner of the policy turns 70.

What qualifies for Accidental Death and Dismemberment?

A car accident with two totaled cars.What are examples of accidental death?

Generally, AD&D riders cover death due to exceptional and unexpected circumstances such as:

  • car accidents;
  • drowning;
  • suffocating or choking to death;
  • freezing to death or heat stroke;
  • burns or fire;
  • homicide;
  • lightning strike;
  • death by heavy equipment;
  • falling.

What is the Number 1 cause of accidental death?

A person lying next to a used needle.In 2018, the CDC reported that the number one cause of accidental death was poisoning, including drug overdose. The second and third leading accidental causes of death were auto accidents and falls.

Accidental Death and Dismemberment Exclusions

It is very important to note that exclusions exist in all Accidental Death and Dismemberment policies for which insurers will deny payment of benefits. Every policy will list exclusions from coverage, and they differ policy-to-policy.  Typically the list will include:

  • Death from natural causes (old age);
  • Death from illness or disease;
  • Suicide (within a certain time frame);
  • Alcohol or drug overdose (poisoning);
  • Death while under the influence of drugs or alcohol;
  • Injuries sustained in war, or death in war.

The policy will also set forth other circumstances, such as if the insured is injured or dies while committing a felony, or if the insured is a professional athlete who is injured or dies while playing his or her sport, or if the insured dies while engaging in a risky or hazardous hobby, such as sky diving or race car driving.

My AD&D claim was denied due to an exclusion – what do I do?

If your claim is denied due to exclusion, let experienced AD&D attorneys help you get paid. In one recent case, for example, our lawyers were able to get the beneficiary paid when the insured fell down a flight of stairs at work and died in the hospital the next day of extensive internal bleeding. The insured also had cirrhosis of the liver. We successfully argued that the pre-existing condition had nothing to do with the death of the insured.

While we cannot guarantee the same result in other matters involving the same facts, we often do get these claims paid.

Is a heart attack considered an accidental death?

Not usually, since a heart attack is usually preceded by a period of illness such as coronary artery disease. The same commonly applies to death by cancer or stroke.

Does AD&D cover drug overdose?

It depends. Was the drug illegal or was it prescribed by a doctor or available over-the-counter? If the overdose was an accident and the insured was prescribed the drug(s), there is always an argument to be made that the beneficiaries should be paid.

If your claim was denied because the insured died from a drug overdose, contact an experienced AD&D attorney to discuss your case – you may yet get paid. In another recent case, we got a beneficiary paid when the insured died as a result of blunt force trauma sustained in a motorcycle accident which left him in the hospital for a month under a DNR order until he finally passed. Our client’s claim was initially denied due to the “acute amphetamine intoxication” of the insured when the accident occurred.

We successfully argued that while operating a motorcycle while intoxicated was negligence, it was still not foreseeable that a motorcycle accident would occur, therefore it was an accident and covered by the AD&D policy.  Our client was paid. Again, we cannot guarantee the same result in any other matter but our success rate is high.

Accidental death payouts and accidental dismemberment payouts

A person laying in a hospital bed with an IV.We can assist an insured in obtaining an AD&D payout if he or she is accidentally seriously injured or suffers dismemberment and no exclusion applies. If the insured dies accidentally or from injuries suffered accidentally, we can help the designated beneficiary obtain the payout if no exclusion applies.

The kind of injuries covered by AD&D includes the loss of use or total loss of a body part, such as a limb or an eye, or important bodily function, such as speech or hearing.

Every policy has different limitations, and the insured should always read the terms of the policy carefully. Examples of injuries that an AD&D policy typically covers include:

  • Loss or loss of use of a limb;
  • Partial or total paralysis;
  • Total or partial loss of sight;
  • Total of partial loss of hearing;
  • Total or partial loss of speech.

While every insurance company offers different coverage and limitations on an AD&D rider, it is unlikely that insurers will pay 100% of the benefit to the insured unless the injuries are extreme, such as if the insured loses a limb and a major bodily function like sight or hearing, or loses two limbs, or is totally paralyzed..

AD&D loss of one limb payouts

This is a frequent cause of litigation, as the insured will believe that the injury is more serious and the AD&D policy should pay a greater percentage of the benefit, and the insurer will argue that the injury is less serious and offers to pay less or even none of the benefit. An experienced life insurance attorney can help you get paid what you deserve in this situation.

What to Do If Your AD&D Claim is Denied

These are the typical causes of claim denial:

  • The accident did not “directly cause” the death or dismemberment or because the death or death occurred too long after the accident;
  • The policy lapsed or was terminated due to unpaid premiums;
  • In the case of employer-provided AD&D coverage, the employee allegedly did not meet the requirements for coverage (e.g., not employed for long enough, not working enough hours, etc.).

A Claim Denied red stamp.If the insurer denies your claim due to policy lapse or termination, or because the employee did not meet the requirements for coverage, contact an experienced AD&D lawyer to help you find out if that is actually the case. Often, there are applicable grace periods or administrative errors that can account for the denial and we can get the denial overturned.

As for denial due to non-accidental death, usually the cause of death is set forth on the insured’s death certificate and the insurance company will make a decision whether to pay out based on that. But what if the information on the death certificate is not, on its face, the whole story?

In one case, we got our beneficiary client paid when the insured drowned, but the death certificate set forth that death “was due to natural causes, relating to an existing heart condition.” We successfully argued that whether an event is an accident depends upon whether it was naturally and probably expected, and the insured would have no reason to expect that he would drown. Again, while we have been successful in overturning many claim denials in cases such as this, we cannot guarantee the same or similar result in any other matter.

If your claim was denied but you believe you have a legitimate claim due to accidental death or dismemberment, try these steps to get paid:

  • Ask the insurer to launch an investigation into the death to determine whether it was accidental;
  • Contact an experienced AD&D attorney to advance your case, especially if the insurance company refuses to investigate.

We have been successful in getting thousands of beneficiaries paid over the years and we can likely help you.

Written By: Chad Boonswang
Chad G. Boonswang, Esquire is a litigation lawyer based in Philadelphia, PA. Selected as an ASLA 2014, 2015, 2016, 2017 and 2018 Top 100 Litigation Lawyer, Mr. Boonswang plays to win. As a lawyer, athlete, and scholar, he has always put in the energy, time, and commitment to be the best. After working for several prominent law firms in Philadelphia, including Montgomery McCracken Walker & Rhoads LLP, he founded his own practice in 2002.  Since then Chad has recovered tens of millions of dollars on behalf of his clients from life insurance claims and catastrophic injury cases.  Year after year, he has earned a 10.00 Superb rating on Avvo.

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