Is it lawful for an insurance company to deny an accidental death claim when the certificate states accidental?
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Is it lawful for an insurance company to deny an accidental death claim when the certificate states accidental?
The death certificate issued states it was accidental. However, the insurance company claims that it wasn’t on behalf of the cause of death (heroin in the system). Their definition of this states that it’s not prescribed, therefore ruling out accident. However, the opposite can be argued because the heroin would not have caused death if the deceased was not taking prescribed medication. I also found it unjust that they “required” years of medical history, when their decision could have been derived from that single certificate.
Asked on May 16, 2012 under Insurance Law, Ohio
Answers:
MD, Member, California Bar / FreeAdvice Contributing Attorney
Answered 11 years ago | Contributor
Go back to your contract and see what there is on definitions of coverage and scenarios of coverage or lack thereof. You need to see if there is a definition of accidental or a limitation on the term accidental. Drug use in this situation (for example, as a drug user) is usually not considered accidental. Think of akin to suicide. Since the insurance company sees this as a deliberate use of non-prescription drugs, it can be considered as non-accidental. But explore it. Contact your state's insurance department and file a consumer complaint for bad faith coverage on those two issues you mentioned (lengthy medical history and denial of coverage) and see if the agency who regulates the entity can give you a better solution.
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