When Accidental Death Insurance Refuses to Pay

Accidental death and dismemberment (AD&D) insurance is often purchased as an addition to life insurance or provided through an employer. Unlike ordinary life insurance, it doesn't cover every death. It pays only when the death qualifies as accidental under the policy. That sounds straightforward, but in practice, it can be surprisingly difficult to agree on what counts as an accident.

What Counts as an Accident?

Was it an accident?

Courts start with ordinary meaning. For employer plans governed by ERISA, the Seventh Circuit reads “accident” as people commonly use the word and asks whether the death was reasonably foreseeable to someone in the insured’s position.

For instance, in Santaella v. Metropolitan Life (7th Cir. 1997), a woman who took too much of a prescribed painkiller died an accidental death, because nothing suggested she meant to harm herself. In Cozzie v. Metropolitan Life (7th Cir. 1998), however, the court upheld a denial after a drunk-driving crash, accepting the insurer’s view that death is a foreseeable result of driving while intoxicated.

Cozzie also shows how much the standard of review matters. The court did not hold that a drunk driver’s death can never be an accident; it held that the insurer’s conclusion was not arbitrary, because the plan gave the insurer discretion. Under a policy without that grant, or one governed by Illinois law rather than ERISA, the same facts receive a closer look.

What If a Medical Condition Contributed to the Death?

Insurance policies frequently require that an accident cause death "directly and independently of all other causes." This language does not necessarily mean that any contributing illness defeats coverage. For instance, in Carlson v. New York Life (1966), an Illinois appellate court rejected the idea that a preexisting condition automatically eliminates accident coverage.

The question is whether the accident was the primary legal cause of the loss, even if another condition contributed. The order of events also matters; a heart attack that causes a crash raises different questions from a crash that triggers a fatal medical complication.

Alcohol or Drugs Exclusion

Many policies add express exclusions for intoxication, for drugs not taken as prescribed, or for injuries sustained while committing a crime. The exact words matter: for instance, an exclusion for death “caused by” intoxication requires a causal link, whereas an exclusion for death occurring “while” intoxicated may not.

A toxicology report may establish that a substance was present, but it does not always establish what caused the death. Depending on the exclusion, the amount detected, timing of the test, and medical evidence may become important.

Where the Claim is Decided

An accidental death rider on an individual policy is governed by Illinois law. A jury may decide disputed facts, and an unreasonable denial can support Section 155 remedies. A benefit through a private employer is usually governed by ERISA, with an internal appeal first, typically due within 60 days of the denial, and review in federal court that is often limited to the record from the appeal. The appeal is where medical opinions, accident reconstruction, and any critique of the toxicology must go in. Group coverage has its own rules, and the appeal deadline is the first thing to find.

If a claim has been denied

Get the full policy or plan, including its definitions of “accident” and “injury” and every exclusion. Obtain the death certificate, autopsy, toxicology results, relevant medical records, and any accident or police reports. Where the cause of death is disputed, an independent forensic pathologist may help identify weaknesses in the insurer's conclusions.

Allison Cho Law handles life insurance claim denials for beneficiaries in Illinois, including accidental death benefits. To discuss a denial, schedule a consultation or contact contact@allisoncholaw.com.

This article is general information, not legal advice.