In short: AD&D benefits turn on two questions: was the death an accident, and does an exclusion apply? Insurers commonly deny claims by pointing to an underlying illness, intoxication, a drug overdose or a risky activity. Most AD&D coverage comes through employers and is governed by ERISA, so the appeal to the plan is usually the critical step.
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How AD&D coverage differs from life insurance
Ordinary life insurance pays on death from almost any cause once the policy is past its early exclusion periods. Accidental death and dismemberment coverage pays only if the death, or a covered loss such as the loss of a limb or sight, resulted from an accident, directly and independently of other causes, and no exclusion applies. The benefit can be as large as, or larger than, the life benefit, so insurers scrutinize these claims closely.
Most AD&D coverage is part of an employer benefit package and is governed by ERISA. That means a denial must usually be appealed to the plan before a lawsuit, and the appeal record is often the only evidence a court will consider. See our ERISA appeals section.
What counts as an accident
Policies often do not define “accident.” Federal courts deciding ERISA cases have developed a test, first set out in Wickman v. Northwestern National Insurance Co., 908 F.2d 1077 (1st Cir. 1990), that asks whether the insured expected the injury, and if the insured’s expectation cannot be determined, whether a reasonable person in the insured’s position would have viewed the injury as highly likely to occur. Courts in different circuits apply versions of that test. Under it, ordinary negligence, such as speeding or a fall from a ladder, does not by itself make a death non-accidental.
Common reasons insurers deny AD&D claims
- Illness or disease. The insurer argues that a heart condition, stroke, seizure or other medical event, not the accident, caused the death, or that the illness contributed to it. Policies use different causation language, and the answer often depends on the medical evidence of what actually happened.
- Intoxication. Many policies exclude losses while the insured was legally intoxicated, or when driving with a blood alcohol level over the legal limit. The exclusion’s exact terms, how the toxicology was done, and whether intoxication actually caused the death all matter.
- Drugs and overdoses. Many policies exclude losses caused by drugs unless taken as prescribed by a physician. Unintended overdoses, combinations of prescribed medications, and fentanyl contamination raise difficult questions under both the accident definition and the exclusion.
- Medical treatment. Exclusions for losses caused by medical or surgical treatment can be raised when a patient dies after a procedure or from a complication.
- Self-inflicted injury, hazardous activities, and crimes. Policies may exclude intentionally self-inflicted injuries, specific activities such as certain aviation, and injuries sustained while committing a felony.
- Timing. Many policies require death within a set period after the accident.
Intoxication exclusions come in two kinds. Some bar coverage whenever the insured was intoxicated. Others apply only if intoxication contributed to the loss, and then the insurer has to prove that link. In Murchison v. Reliance Standard Life Insurance Co., the insured died when his ATV rolled down a creek bank, and his toxicology showed alcohol and a pain medication. Reliance denied the $597,000 AD&D claim, saying both contributed to the accident. A federal court in Tennessee reversed the denial: the investigating officer could not say alcohol or medication played a role, Reliance’s own reviewing pathologist would not say they contributed, and a blood alcohol level alone does not prove causation.
Some state insurance laws also limit how far a drug or intoxication exclusion can go. In Gambino v. Metropolitan Life Insurance Co., a federal court in California held that ERISA does not preempt California’s statute, which allows an exclusion for drugs only when they were not taken on a doctor’s advice, and that the statute applied to a California employee’s coverage under an employer plan, even though the policy said Massachusetts law governed.
In one Missouri family’s case, Prudential denied AD&D benefits after a wife died of an accidental overdose of medications her doctors had prescribed, saying an overdose is not a bodily injury and that the death fell under the policy’s exclusion for sickness and its treatment. We appealed twice, arguing that an overdose is an injury in the ordinary sense of the word and that a sickness exclusion cannot cancel the policy’s own exception for drugs taken as a doctor prescribed. Prudential paid the $640,000 AD&D benefit, and no lawsuit was needed.
Building the claim
AD&D disputes are won with evidence about how the death happened. Depending on the facts, that can include the complete autopsy and toxicology reports, police and crash reports, scene photographs, emergency and hospital records, witness statements, and an independent review by a forensic pathologist or toxicologist. In an ERISA case, this evidence must generally be submitted during the plan appeal.
How we help
We obtain the full policy or plan and the claim file, identify the exact language the insurer relied on, and gather the medical and investigative evidence needed to answer it. We review AD&D denials at no cost. If the life insurance portion of the coverage is also disputed, see our pages on denied claims and beneficiary disputes.
Common questions
Is an overdose an accident under AD&D coverage?
It depends on the policy language and the facts. Many policies exclude drug overdoses except for drugs taken as prescribed, and courts have reached different results on unintended overdoses. The precise exclusion wording matters.
The insurer says my relative's illness contributed to the death. Does that end the claim?
Not necessarily. Courts look at the policy's causation language and whether the illness was a substantial cause or merely a condition present at the time. Medical opinion evidence is often decisive.
What if the death certificate says the manner of death was undetermined?
An undetermined manner of death does not mean the death was not an accident. The insurer must apply the policy terms to all of the evidence, and additional records or an independent medical review can change the analysis.
Is there a time limit between the injury and death?
Many AD&D policies require death within a set period after the accident, often 90 or 365 days. Some courts have refused to enforce such limits in particular situations, so check the policy and talk to an attorney.
Written by the attorneys of Interpleader Law. General information, not legal advice; the law differs by state and by policy, and every case turns on its own facts.