Many employers today provide group life insurance coverage for their employees. A benefit adjacent to group life insurance is accidental death and dismemberment (“AD&D”) insurance. AD&D insurance pays you a benefit if you lose a limb or an eye, or it may pay your beneficiary additional life insurance benefits if you die in an accident.
Most AD&D policies define accident with terms like “sudden,” “unforeseeable,” “unintentional,” and “external cause” – not exactly concrete and easy to follow guidelines to determine whether a death was accidental or not. When a claim is made to an insurance company for accidental death benefits, the insurer considers the events and actions that caused the person’s death and decides whether the claim meets the policy’s definition of accident. If the death was caused by an injury and not an illness, how did that injury happen? Was the person going about their normal life and was struck down in some way that they did not expect? Were they doing something dangerous and likely to cause injury? As one judge said: “What is an accident? Everyone knows what an accident is until the word comes up in court. Then it becomes a mysterious phenomenon, and, in order to resolve the enigma, witnesses are summoned, experts testify, lawyers argue, treatises are consulted and even when a conclave of twelve world-knowledgeable individuals agree as to whether a certain set of facts made out an accident, the question may not yet be settled, and it must be reheard in an appellate court.” Brenneman v. St. Paul Fire and Marine Ins. Co., 411 Pa. 409, 192 A.2d 745, 747 (1963)
The decision of whether a death was an accident often hinges on whether the person’s death was “foreseeable.” When analyzing whether a death was foreseeable, the insurer generally first considers whether the person expected to be seriously injured as a result of their actions. Consider a scenario where a person died when they were injured diving off a tall cliff. If that person was a champion cliff diver and regularly dove off tall cliffs, they would not expect to be seriously injured performing such a dive. Second, the insurer considers whether that expectation was reasonable. In the case of our cliff diver, because she had been cliff diving regularly without injury, her expectation to not be injured while cliff diving was reasonable. This analysis becomes more confused in the real world where the facts are not always so clear.
Even if a death is determined to be an accident as defined in the AD&D policy, there are generally still exclusions that an insurer can use to avoid paying claims. If the person died while committing a felony, while imprisoned, as a result of surgery or medical treatment, or driving while intoxicated, even if their death was an accident the insurer may still deny the claim based on a policy exclusion.
If you have had an AD&D claim denied by the insurer, an attorney who has experience with AD&D claims will be able to help you understand the AD&D policy’s language. Please call Kantor & Kantor for a free consultation at 888-569-6013 or use our online contact form. Our firm has handled many AD&D cases and can help you appeal a claim denial or bring a lawsuit to obtain the AD&D benefits.