Life Insurance Claim Articles

Notes To Selves Regarding The Denial Of The Rolling Stones’
$12,700,000 Claim

By Jeffrey L. Greyber, Esq.

Recently, a $12,700,000 claim submitted by the Rolling Stones / Mick Jagger was denied.

Check out the article.

I am not privy to the policy language underlying the Rolling Stones’ claim, so I cannot opine as to the (im)propriety of the carrier’s claim decision. But the above article inspired me to point out a few things to life and disability insurance claimants / policyholders.

First, I’m often approached by life insurance beneficiaries confronted with a suicide-based claim denial. Most (if not all) life insurance policies that I have ever seen include a suicide exclusion. Here is an example: “If the Insured dies by suicide, whether sane or insane within two years from the Issue Date, the only amount payable by Us will be premium paid for the Policy.” There are very few ways to dispute a suicide-based claim denial. One way is the policy language itself. For example, equipped with the policy language quoted above, there would obviously be an argument for coverage if the suicide occurred within the third policy year or beyond. Another way is a cause of death analysis, which, of course, would be aimed at determining whether the death was truly the result of suicide or whether the death was accidental or natural. Although the mountain to climb in unraveling a suicide-based claim denial is steep, it is not an impossible climb when equipped with liberal or ambiguous policy language and / or an analysis from a medical, coroner, and / or lab examiner.

Second, I’m often approached by disability insurance claimants confronted with a “not under the regular care of a doctor” claim denial. Most (if not all) disability insurance policies that I have ever seen build a “care or treatment” requirement into the definition of “disability.” Here is an example: “Benefits are provided for the Insured’s total or partial disability only if… (b) the Insured is under the Regular Care of a Licensed Physician during disability.” The policy that included this language defined “Regular Care” as:

… personal and in-person care and treatment by a Licensed Physician trained to treat the condition causing the disability. The care and treatment received by the Insured shall be in accordance with the medical standard of care appropriate to the condition causing the disability. The care and treatment shall be designed to lead to the Insured being able to return to the principal duties of the regular occupation or gainful employment in any occupation. If the Company determines that Regular Care of a Licensed Physician would be of no further use to the Insured, the requirement of such care will be waived.

There are several ways around a “not under the regular care of a doctor” claim denial. The most glaring way is a proper application of the facts to the subject policy language; i.e., achieving a perfect understanding of the nature of the disability at hand and conveying same to the carrier in a way that is both coherent and grounded in policy language. For example, is the disability chronic in nature or is surgery the only solution? If so, there would be a good argument that treatment “would be of no further use to the Insured” and the insured would not be required to continue to visit with the physician. As another example, just because the insurance company’s medical examiner (who is likely only reviewing paper in arriving at a decision, as opposed to actually examining the disabled claimant) says that the subject care or treatment is not “in accordance with the medical standard of care” does not mean that that is the case. Reasonable minds in the medical community can differ, and such a declaration from a carrier medical examiner can often be refuted. Of course, it is industry standard that a tie goes to the policyholder.

Stay well, my friends.

Related Denied Life Insurance Claim Articles

Life Insurance Claim Denied, Application Misrepresentation

By Jeffrey L. Greyber, Esq.

I have noticed arising issues in the life insurance arena as of late, and I would like to offer some practical tips to you, the policyholder. There are many unfortunate circumstances that can emanate when it comes to the life insurance field. For instance, if you are in the deplorable position of a loved one, with a life insurance policy, passing away. I have seen many times, the insurance company deny the claim because it dictates on the application that there are misrepresentations in the life insurance policy application.

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Life Insurance Claim Articles