AD&D Insurance Benefit Denials

Most employees do not think much about their Accidental Death & Dismemberment (AD&D) insurance. It is often buried in an onboarding packet or lumped into your benefits summary next to dental or vision. You do not expect to need it. But when a serious accident occurs, AD&D is supposed to be there as a safety net for you or your family.

Many policyholders only learn how aggressively insurers fight AD&D claims after a tragedy. These policies, which are almost always governed by ERISA, are structured to limit your rights and give insurers wide discretion to deny claims, even when the injury or loss clearly qualifies.

At Sandstone Law Group, we represent employees and families who have had their AD&D claims denied, delayed, or underpaid. Whether the case involves loss of life or catastrophic injury, we understand how insurers twist policy language, weaponize exclusions, and hope you will walk away without a fight. We do not let that happen.

What Is AD&D Insurance?

AD&D insurance provides financial protection after an unexpected accident, whether that accident results in the insured’s death or a life-altering injury. Often included in employer-sponsored benefits packages, these policies promise a lump-sum payout when tragedy strikes. 

If an insured person dies due to a covered accident, the policy’s designated beneficiaries are typically entitled to a lump-sum death benefit. This payout is meant to provide immediate financial support to surviving family members, especially in cases where the deceased was a primary income earner. But qualifying for that payout is not always as straightforward as it seems, particularly under policies governed by ERISA, where insurers have broad authority to interpret both the cause of death and the definition of an “accident.”

In cases where the insured survives the accident but suffers a serious physical loss, AD&D policies typically offer tiered benefits based on the severity and type of dismemberment. These can include losses such as:

•  Loss of a single limb, eye, or sense (speech or hearing).
•  Loss of two or more limbs, or multiple senses.
•  Paralysis, coma, or permanent loss of use.

Importantly, “dismemberment” under AD&D is not always limited to amputation. It can include total and permanent loss of function (such as vision, hearing, or mobility) if the condition results from an accident.

However, insurers often dispute what qualifies as a “covered accident,” particularly when medical history or pre-existing conditions are involved. If you suffered an injury that permanently impaired your ability to see, walk, speak, or perform major life functions, and the insurer claims it doesn’t qualify because of a prior surgery or diagnosis, you’re not alone, and you may still be entitled to full or partial benefits.

What AD&D Insurance Typically Covers  

AD&D benefits are paid when a covered accident results in death or a qualifying dismemberment. In general, these policies provide:

• Full death benefit if the insured dies as a direct result of a covered accident, often within a specified time frame.
• Partial benefit payouts for non-fatal but serious injuries, including:
  • Loss of one or more limbs
  • Loss of sight in one or both eyes
  • Loss of hearing or speech
  • Paralysis (partial or total)
  • Coma or severe brain injury
  • Disfigurement, in some cases.

Some policies also include additional provisions such as:

• Seatbelt or airbag benefits for car accident fatalities
• Education benefits for surviving dependents
• Repatriation benefits to cover the transport of remains.

Common Exclusions and Denial Tactics

AD&D denials are often based on circular logic or exaggerated exclusions. We have seen insurers deny benefits for clients who lost an eye, limb, or function because of reasons that defy common sense. As an example, a claimant could lose an eye in a workplace accident, and the insurer could try to deny the claim by arguing their prior LASIK surgery made them more susceptible to injury, even though the injury was clearly traumatic and directly caused by an accident.

While AD&D coverage may sound comprehensive, most policies contain extensive exclusions that insurers rely on to deny benefits, often wrongfully. These exclusions can include:

• Time Lapse Between Accident and Death: Some AD&D policies impose strict timelines, such as requiring that death occur within 90 days of the accident, for benefits to apply. Insurers may deny a claim if medical complications prolong life beyond that window. They may also argue that intervening treatments, infections, or unrelated health events caused the death, rather than the initial accident. However, in many cases, these claims can be successfully challenged by demonstrating that the chain of events originated with the accident.
• Pre-Existing Illness or Comorbidity: If the deceased had a known health condition at the time of the accident, insurers could argue that the illness—not the accident—was the true cause of death. This is especially common when the policyholder had chronic conditions like diabetes, cancer, or autoimmune diseases. But having a pre-existing illness does not preclude coverage if the accident itself was the primary cause of death or dismemberment. These denials often require a thorough medical and legal rebuttal. But having a pre-existing illness does not preclude coverage if the accident itself was the primary cause of death or dismemberment. These denials often require a thorough medical and legal rebuttal.
• Heart Attacks and Strokes: Heart attacks and strokes are frequently used as grounds for denial, with insurers asserting that such events are medical conditions, not accidents. Yet context matters. If a stroke or cardiac event was caused or worsened by external trauma (e.g., a fall or crash), or occurred during a triggering incident like extreme exertion on the job, there may be grounds to argue that the death was accidental under the policy’s terms.

• Substance use or intoxication: If any alcohol or substances, prescription or otherwise, were found in the deceased’s system, insurers may use this as a basis to deny benefits, even when the substance had little or nothing to do with the actual accident. The presence of a substance is not the same as proof of causation. Courts have rejected blanket denials that fail to show a direct and dominant connection between intoxication and the fatal event.
• Self-inflicted injuries or suspected death by suicide: Many AD&D policies exclude coverage for suicide or intentionally self-inflicted injuries. However, insurers sometimes invoke this exclusion based on assumptions, circumstantial evidence, or ambiguous autopsy findings. If the cause of death is unclear or contested, the burden is on the insurer to prove that it falls under an excluded category, and many push that boundary without adequate justification.
• High-risk activities: Insurers frequently deny claims by suggesting the policyholder “assumed the risk” of injury. If your loved one died while engaging in activities like rock climbing, motorcycling, or skiing, the insurance company may argue that the death was not truly accidental. However, engaging in a high-risk activity does not automatically negate coverage. Many of these policies are silent or ambiguous about such risks, and exclusions must be clearly spelled out and narrowly applied.
• Aircraft Accidents: Deaths that occur during private flights are often excluded, particularly if the decedent was the pilot or the flight was not for commercial purposes. However, the enforceability of such exclusions depends on specific policy language and the facts of the crash. Not all private aircraft incidents are disqualified, and vague or poorly written exclusions can be contested.
• War, acts of terrorism, or military service: These events are almost always excluded, even if the injury was accidental.

Insurers frequently use these exclusions to stretch the interpretation of what qualifies as an “accident.” They may also argue:

• That an illness contributed to the accident, even tangentially
• That the injury did not meet the policy’s narrow definition of “dismemberment”
• That death occurred too long after the accident to trigger benefits.

AD&D and ERISA: What You Need to Know

Almost all AD&D policies are offered as part of an employer-sponsored benefits package. While many employees do not even realize they have this coverage until a tragedy occurs, these policies are governed by a strict and complex federal statute: ERISA.

ERISA was designed to create uniform standards for employee benefit plans across the country. But for beneficiaries trying to access their rightful AD&D benefits, it often works to the insurer’s advantage. If your claim has been denied, ERISA sets the rules for what evidence is considered, how appeals must be handled, and where and how a lawsuit can be filed. Unfortunately, most people only learn this after their claim has been rejected.

Under an ERISA-governed AD&D plan, your claim is not handled like a private contract dispute; it is administered by a plan administrator, usually acting on behalf of the insurance company. If your claim is denied, you cannot file a lawsuit immediately. You must first complete an administrative appeal directly with the insurer, typically within 180 days. Only after this internal process is exhausted are you allowed to pursue your case in federal court.

This appeals process can be the foundation of your entire case. That is because in ERISA litigation, the court will generally only review the evidence you submitted during your administrative appeal. If key medical records, legal arguments, expert opinions, or documentation are missing at that stage, you likely won’t be allowed to add them later.

For that reason, your appeal must be built as if you are preparing for trial from day one. Every word, every exhibit, and every omission matters. A mistake at this stage could cost you the entire claim.

Why You Need an Attorney Who Understands ERISA

ERISA is notoriously unforgiving to claimants. There are no juries, no punitive damages, and very limited opportunities for discovery. The court often defers to the insurer’s decision, unless you can prove that the decision was arbitrary or tainted by a conflict of interest. Doing so requires a highly strategic approach grounded in ERISA precedent, administrative law, and a deep understanding of how insurers manipulate claim files to defend denials.

At Sandstone Law Group, we have extensive experience navigating the ERISA claims process. We know how to build strong, evidence-backed appeals that preserve your right to challenge a wrongful denial in court. From day one, we treat your case as if it is going to trial, because under ERISA, it might. Working with an experienced ERISA lawyer ensures that your appeal is strategically prepared and legally sound.

How Sandstone Law Group Can Help

We have handled complex AD&D disputes under both employer-sponsored and private policies. When you hire us, we bring deep knowledge of:

• ERISA regulations and federal court strategy
• Medical documentation and accident reconstruction
• Policy interpretation and exclusion challenges
• Insurer delay and denial tactics.

We build your appeal from the ground up, with the assumption that it may go to litigation. That means:

• Collecting and organizing medical and accident records
• Challenging the insurer’s interpretation of “accidental,” “loss,” or “cause”
• Engaging medical and forensic experts when needed
• Filing aggressive appeals that preserve your right to sue if necessary.

We also pursue litigation when an insurer refuses to act in good faith. Although ERISA limits damages, we maximize your claim by identifying procedural violations, conflicts of interest, and case law that supports your right to benefits.

Let Us Help You Fight Back.

The pain of losing someone in an accident or adjusting to life after a disabling injury is hard enough. You should not have to fight an insurance company just to receive the benefits that were supposed to be there when it mattered most.