Accidental Death Claim Denied Due to Sickness Exclusion

If an insurance company denied your accidental death claim by arguing that "sickness" — not an accident — caused the death, you need to know one thing before you give up: this is one of the most commonly misapplied denials in life insurance law, and it is frequently overturned.

Insurance companies apply the sickness exclusion aggressively because it saves them money. But applying it broadly does not make it legally valid. Courts across the country have repeatedly sided with beneficiaries when insurers stretch the sickness exclusion beyond what the policy language actually supports. Related: Accidental death denied due to alcohol or intoxication →

At Kadetskaya Law Firm, LLC, we have recovered accidental death benefits in cases involving exactly this denial — including a recovery from Prudential where the insured had a substance in his system and died in a motorcycle accident, and a recovery from CUNA where the insured choked on food and the insurer tried to apply the sickness exclusion. Not sure what to do next? Read our step-by-step denial guide →

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What Is the Sickness Exclusion in an Accidental Death Policy?

Most accidental death and dismemberment policies — and accidental death riders on life insurance policies — contain a sickness exclusion. This exclusion states that the policy will not pay benefits if death was caused by illness, disease, or bodily infirmity rather than by an accident. On its face, the exclusion seems straightforward. In practice, it is anything but. The problem arises when an insured had an underlying medical condition and also suffered an accident. In those cases, insurers routinely deny the claim by pointing to the medical condition — even when the accident was the direct and primary cause of death.

The Central Legal Question: What Actually Caused the Death?

When an insurer denies an accidental death claim based on the sickness exclusion, the central legal question is not whether the insured had a medical condition. The question is:

Was the accident the proximate cause of death — or was the sickness?

This is a critical distinction. Courts have consistently held that an insurer cannot invoke the sickness exclusion simply because a medical condition existed. The insurer must prove that the sickness — not the accident — was the primary, proximate cause of death. If the accident set off a chain of events that led to death, the claim is generally payable — even if an underlying condition made the outcome more likely or more severe.

Common Scenarios Where Insurers Wrongfully Apply the Sickness Exclusion

Scenario 1 — Fall with underlying osteoporosis or heart condition

The insured falls and suffers fatal injuries. The insurer denies the claim arguing the fall was caused by a fainting episode or heart event. Courts have found these denials invalid when the fall itself was the cause of death, regardless of what triggered the fall.

Scenario 2 — Car accident with pre-existing conditions

The insured dies in a car accident. The insurer discovers the insured had diabetes, hypertension, or cardiovascular disease and argues the accident was "medically induced." Courts have rejected these arguments when the accident was clearly the cause of death.

Scenario 3 — Drug or alcohol in the system

The insured dies in an accident and a toxicology report shows a substance in their system. The insurer applies the narcotic or intoxication exclusion — sometimes alongside the sickness exclusion — to deny the claim. Courts have required insurers to prove the substance actually caused the accident, not merely that it was present.

Related: Accidental death denied due to drugs →

Scenario 4 — Choking, drowning, or suffocation

The insured chokes on food, drowns, or suffocates. The insurer argues the event was related to a swallowing disorder, seizure, or other medical condition. Courts have found these claims payable when there is no clear evidence a medical condition was the primary cause.

Scenario 5 — Heart attack during physical activity

The insured suffers a cardiac event while exercising, shoveling snow, or engaging in another physical activity. The insurer denies on sickness grounds. Courts have held that if the physical activity triggered the cardiac event, coverage may still apply depending on the policy language and causation analysis.

What the Law Requires Before an Insurer Can Deny on Sickness Grounds

Insurance companies do not get to simply assert that a sickness caused the death. To validly deny an accidental death claim under the sickness exclusion, the insurer generally must establish all of the following:

1. The policy language clearly and unambiguously covers the denial scenario.

Exclusions are interpreted strictly and narrowly under the law. If the policy language is ambiguous — meaning a reasonable person could read it two different ways — courts resolve the ambiguity in favor of coverage, not the insurer.

2. The sickness was the proximate cause of death — not just a contributing factor.

The mere existence of a medical condition does not satisfy this requirement. The insurer must demonstrate that the medical condition, independent of any accident, was the primary cause of death.

3. The denial is supported by medical evidence.

The insurer cannot rely on speculation or a reviewing physician's opinion that contradicts the treating physician, medical examiner, or coroner without a compelling evidentiary basis.

4. The insurer followed proper claims handling procedures.

An insurer that rushes to deny without a thorough investigation, ignores evidence supporting coverage, or fails to explain its reasoning clearly may be acting in bad faith — exposing itself to additional damages beyond the policy benefits.

How Courts Interpret Accidental Death Policies

Courts in most states apply one of two standards when analyzing accidental death exclusions:

The "but for" test: Would the death have occurred but for the accident? If the answer is no — meaning the insured would have survived but for the accident — the death is accidental and the claim is payable.

The proximate cause test: Was the accident the proximate — meaning primary or dominant — cause of death? If yes, the claim is payable even if a medical condition was a contributing factor.

Under both standards, insurers face a demanding burden when trying to invoke the sickness exclusion in a case involving a clear accident. Courts have specifically held that an insurer cannot avoid liability simply because an underlying illness made the insured more vulnerable to an accidental injury.

ERISA and the Sickness Exclusion

If the accidental death policy was provided through an employer — as part of a group benefits plan — it is most likely governed by ERISA. ERISA sickness exclusion denials follow different procedural rules:

- You must file an administrative appeal before you can sue

- Appeal deadlines are strict — typically 60 to 180 days from the denial letter

- Courts review the insurer's decision under a deferential standard in many cases

- The evidence you submit during the appeal is critical — once the record closes, you generally cannot add new evidence in court

ERISA accidental death denials based on the sickness exclusion are among the most frequently litigated cases in federal court. Many have been reversed when courts found the insurer's interpretation of "sickness" was arbitrary and not supported by the policy language or the medical evidence.

What You Should Do If Your Claim Was Denied

Step 1 — Get the complete denial letter in writing.

The insurer must explain exactly why it applied the sickness exclusion. If the explanation is vague or unsupported, that is itself a basis for challenge.

Step 2 — Request the complete claim file.

You are entitled to every document the insurer relied on — including the medical review, any physician opinions, and internal communications. Request this immediately and in writing.

Step 3 — Obtain your own medical evidence.

The treating physician's opinion, the medical examiner's report, and the death certificate are all critical. If the insurer is relying on a hired reviewing physician who never examined the insured, that opinion can be challenged.

Step 4 — Review the policy language carefully.

Sickness exclusion language varies significantly from policy to policy. Ambiguous language is construed in favor of coverage. An attorney can identify whether the exclusion as written actually applies to the facts of your case.

Step 5 — Do not miss your appeal deadline.

For ERISA plans, the appeal window can be as short as 60 days. For individual policies, contractual and state law deadlines apply. Missing the deadline can permanently forfeit your right to benefits.

Step 6 — Contact a life insurance attorney.

Sickness exclusion cases require a detailed analysis of policy language, medical causation, and applicable law. An experienced attorney can identify the weaknesses in the insurer's position and build the strongest possible case for recovery.

Our Experience With Sickness Exclusion Denials

Kadetskaya Law Firm, LLC has recovered accidental death benefits in multiple cases where insurers applied the sickness exclusion:

- Recovery from Prudential — accidental death claim denied under a narcotic exclusion where the insured had marijuana in his system and died in a motorcycle accident. We argued the substance did not cause the accident and recovered the full benefit.

- Recovery from CUNA — accidental death claim denied under the sickness exclusion after the insured choked on food and died. We challenged the application of the exclusion and recovered the full benefit.

- Recovery from Broadspire/Federal Insurance Company — accidental death claim denied under both intoxication and narcotic exclusions after the insured drowned in a hot tub. We recovered the full benefit.

- Recovery from The Guardian — accidental death claim denied because the medical examiner listed the manner of death as undetermined. We argued that undetermined does not mean non-accidental and recovered the full benefit.

***Prior results do not guarantee a similar outcome.

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Frequently Asked Questions

Can an insurer deny an accidental death claim just because the insured had a pre-existing condition?

No — not automatically. The insurer must prove the pre-existing condition, not the accident, was the primary cause of death. A medical condition that made the insured more vulnerable to an accidental injury does not by itself justify denial.

What if the person had a heart attack during the accident?

Coverage may still apply depending on the sequence of events and causation. If the accident triggered the cardiac event — rather than the cardiac event triggering the accident — courts have found the death accidental and the claim payable.

What if the death certificate lists the manner of death as "undetermined"?

Undetermined does not mean non-accidental. Courts have rejected insurer arguments that an undetermined manner of death automatically supports a sickness exclusion denial. An attorney can challenge this interpretation.

What if the medical examiner's report supports the insurer's position?

Medical examiner opinions can be challenged. Treating physician opinions, independent medical expert opinions, and a detailed analysis of the circumstances of death can all be used to counter the insurer's medical evidence.

Does the sickness exclusion apply differently under ERISA?

Yes. ERISA cases are decided in federal court under a deferential standard of review in many cases. However, courts have frequently reversed ERISA sickness exclusion denials when the insurer's interpretation of the exclusion was arbitrary, unsupported, or inconsistent with the policy language.

How long do I have to appeal a sickness exclusion denial?

For ERISA plans, typically 60 to 180 days from the denial letter. For individual policies, the deadline depends on the policy terms and state law. Contact an attorney immediately — missing the deadline can permanently bar recovery.

How much does it cost to hire a life insurance attorney for a sickness exclusion case?

Kadetskaya Law Firm, LLC handles all accidental death cases on a contingency fee basis. You pay no attorney fees unless we recover your benefits. There are no upfront costs and no hourly charges.

Contact Kadetskaya Law Firm, LLC

If your accidental death claim was denied because the insurer claimed sickness caused the death, do not accept that denial without speaking to an attorney. These cases are frequently overturned and the stakes — a full accidental death benefit — are significant.

(888) 510-2212

Free Consultation.

We represent ERISA clients nationwide. No fees unless we win.

Kadetskaya Law Firm, LLC

630 Freedom Business Center Dr, 3rd Floor

King of Prussia, PA 19406

Tel. (888) 510-2212

info@life-insurance-lawyer.com

This page is for general informational purposes only and does not constitute legal advice. Contact our firm directly for advice specific to your situation.