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Kantor & Kantor LLP 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.
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.
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:
The attorneys of Kantor & Kantor LLP 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:
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.
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