How Insurers Misuse the Misdemeanor Exclusion — Two Real Cases
How Insurance Companies Misuse the Misdemeanor Exclusion to Deny Accidental Death Claims
When a family member dies in an accident and you file an accidental death claim, you expect the insurance company to investigate what caused the death. What you do not expect is for the insurer to comb through the circumstances looking for a technical legal violation — no matter how minor, no matter how unrelated to the death — and use it to deny your family the benefits they are owed.
That is exactly what the misdemeanor exclusion is used for.
Most accidental death and dismemberment policies contain an exclusion for deaths that occur while the insured was "committing or attempting to commit a felony or misdemeanor." In the right circumstances, that exclusion may be legitimate. But in our experience, insurers apply it far beyond what the policy language actually supports — denying valid claims based on speculative misdemeanor allegations that have no real connection to the cause of death.
Two cases our firm handled against the same insurer — Lincoln National Life Insurance Company — illustrate this pattern clearly. Both involved accidental deaths in car accidents. Both were denied under the misdemeanor exclusion. Both denials were legally wrong. And in both cases, we recovered the full accidental death benefit for the surviving families.
Case One: The Downed Stop Sign, the Fabricated Exclusion, and the Unreliable Toxicology Report
The first case involved a woman driving to work at 6 a.m. when she was struck by a semi truck at an intersection. The coroner listed her manner of death as an accident due to multiple blunt force injuries. The police report noted she had failed to stop at a stop sign — but it also noted something far more significant: a second stop sign at that intersection had been knocked down and was lying face-down in the southwest corner of the intersection. A dash camera on the semi truck confirmed the downed stop sign was not up at the time of the crash. The Ohio Department of Transportation had no knowledge the sign was down. It had apparently been struck by another vehicle and left unreported. The police report stated multiple times that alcohol did not play a role in the accident.
Despite all of this, Lincoln denied the accidental death claim. And Lincoln's denial revealed something remarkable: the denial letter relied on an alcohol exclusion that did not exist anywhere in the actual group life insurance policy. Lincoln had invented an exclusion and inserted it into the denial letter.
Lincoln also relied on a postmortem toxicology report showing a blood alcohol level at exactly the legal limit of 0.08. Our appeal challenged this result on scientific grounds. The blood sample was taken two days after death from the insured's aorta — an organ that had been severely lacerated in the crash. Postmortem blood alcohol readings are inherently unreliable for several documented reasons: bacterial fermentation in the body after death can produce alcohol endogenously, contamination from lacerated gastrointestinal organs can artificially elevate readings, and swabbing with antiseptic during sample collection can further inflate the result. We cited peer-reviewed forensic science literature and federal court decisions recognizing the unreliable nature of postmortem BAC readings taken under these conditions.
Beyond the science, we argued that Lincoln failed to meet the legal standard required by its own policy. Exclusion 5 — the misdemeanor exclusion — required Lincoln to prove a causal connection between the alleged misdemeanor and the death. That standard is established by decades of Sixth Circuit precedent. The question was not whether the insured had alcohol in her system. The question was whether alcohol caused her death. The answer, supported by the police report, the coroner's findings, the dash camera footage, and the downed stop sign, was clearly no. The sole proximate cause of her death was the blunt force trauma from the semi truck collision — a collision that any driver, sober or not, might not have survived at an intersection with a downed stop sign. Lincoln paid the full accidental death benefit.
Case Two: The Speculative Citation, the Worn Tires, and the Exhaust Fumes
The second case involved a different set of facts but the same insurer and the same exclusion. A woman died when her 2004 Chevrolet Malibu rolled over and struck a concrete median while she was driving to work. The coroner ruled her death an accident caused by blunt force head injuries. The police report noted that the vehicle had excessively worn rear tires — measured at 3/32 of an inch, compared to 11/32 on a new tire.
Lincoln's claims examiner called the state trooper who responded to the scene and asked whether a misdemeanor or felony could be ruled out. The trooper responded by voicemail: if the insured had survived, she would have been issued a minor misdemeanor citation for failure to control her vehicle. That phone call became the entire basis for Lincoln's denial. Our appeal identified multiple fundamental problems with this reasoning. First, a citation is not a conviction. Under Ohio law, citations can be dismissed by the prosecutor if there is insufficient evidence to warrant prosecution. Lincoln had no basis to assume the citation would have survived, let alone resulted in a misdemeanor finding.
Second, Ohio law recognizes a sudden emergency defense to traffic violations — an affirmative defense available when something beyond the driver's control made it impossible to comply with the traffic statute. The record contained direct evidence of two such emergencies: the excessively worn rear tires, which the National Highway Traffic Safety Administration identifies as a leading cause of single-vehicle accidents, and a hole in the exhaust pipe that the insured's husband confirmed had been present for several weeks before the crash. A hole in the exhaust pipe can allow carbon monoxide fumes to seep into the vehicle's interior, potentially causing dizziness or impairment.
No witness observed the accident. No camera captured the rollover. The traffic camera was facing downward and recorded nothing. Lincoln had no evidence of what actually caused the vehicle to lose control — only speculation.
Third, and most fundamentally, Lincoln never established that any alleged misdemeanor caused the death. The policy exclusion required causation — proof that the commission of a misdemeanor caused or contributed to the death. A speculative citation that might have been issued, might not have been dismissed, and might have resulted in a misdemeanor conviction is not evidence of causation. It is conjecture stacked on conjecture.
The insured could not be questioned. She died at the wheel of an 18-year-old car with bald tires and a compromised exhaust system. The record could not be ignored. Lincoln paid the full accidental death benefit.
What These Two Cases Reveal About the Misdemeanor Exclusion
Both cases share a common pattern that we see repeatedly in accidental death denials involving the misdemeanor exclusion:
The insurer looks for any technical violation, however minor.
In Case One, a postmortem BAC at exactly the legal limit — from an unreliable sample taken two days after death. In Case Two, a speculative citation that a trooper said might have been issued if the insured had survived. Neither rises to proof of a misdemeanor. Neither establishes that a misdemeanor caused the death. But both were used as the basis for denying significant accidental death benefits to grieving families.
The insurer ignores evidence that undermines its position.
In Case One, Lincoln ignored the downed stop sign, the dash camera footage, the police report's repeated statements that alcohol played no role, and the documented unreliability of postmortem BAC readings from lacerated organs. In Case Two, Lincoln ignored the worn tires, the exhaust fumes, the absence of witnesses, the absence of camera footage, and the Ohio sudden emergency defense. An insurer that selectively reads a claim file to find denial grounds while ignoring exculpatory evidence is not investigating in good faith.
The insurer does not meet its own burden.
The misdemeanor exclusion in both policies required the insurer to prove causation — that the commission or attempted commission of a misdemeanor caused the death. In both cases, Lincoln never established this link. It pointed to a toxicology reading or a speculative citation and called it done. That is not proof of causation. Courts have long held that the insurer bears the burden of establishing that an exclusion applies — and a conclusory assertion is not evidence.
The insurer invents exclusions that do not exist.
In Case One, Lincoln inserted an alcohol exclusion into the denial letter that appeared nowhere in the actual group policy. This is not a drafting error. It is the use of a fabricated policy provision to deny a legitimate claim.
The Legal Standard Insurers Must Meet
If you have received an accidental death denial based on the misdemeanor exclusion, the insurer must prove all of the following before the denial is legally valid:
1. The policy exclusion actually covers the alleged activity.
Many policies limit the misdemeanor exclusion to felonies only. If the policy says "felony" and the alleged conduct was a misdemeanor, the exclusion does not apply. Even where misdemeanors are covered, the policy language must be unambiguous — and ambiguous exclusion language is construed against the insurer under the principle of contra proferentem.
2. The insured actually committed a misdemeanor.
A speculative citation, a trooper's informal opinion, or a postmortem toxicology reading with documented reliability problems is not proof of a misdemeanor. The insurer must establish that a misdemeanor actually occurred — not that one might have occurred under different circumstances.
3. The misdemeanor caused the death.
This is the most important requirement and the one insurers most frequently fail to satisfy. The exclusion requires a causal connection between the misdemeanor and the death. The presence of a technical legal violation at the time of death — without proof that the violation caused the fatal event — is not sufficient. Courts across multiple federal circuits have held this standard consistently.
What You Should Do If Your Claim Was Denied Under the Misdemeanor Exclusion
Get the complete claim file immediately. Request every document the insurer relied on — not just the denial letter. In both cases described above, the claim files contained information that directly undermined the denial.
Read the exact exclusion language. Is it limited to felonies? Does it require causation? Is the language clear or ambiguous? The specific words matter enormously.
Challenge the factual basis of the alleged misdemeanor. Was a citation actually issued? Was there a conviction? Was the allegation based on a toxicology reading, a trooper's speculation, or actual evidence?
Identify independent causes of the accident. Road conditions, vehicle defects, third-party negligence, downed signs, worn tires, mechanical failure — any of these can establish that something other than the alleged misdemeanor caused the death, defeating the causation requirement.
Do not miss your appeal deadline. For ERISA plans — which cover most employer-provided accidental death policies — the appeal window is typically 60 to 180 days from the denial letter. Missing it can permanently forfeit your right to the benefits.
Contact a life insurance attorney. Misdemeanor exclusion cases require analysis of policy language, the specific facts of the death, applicable federal and state law, and ERISA procedures. An attorney who knows these cases can identify the strongest arguments specific to your situation.
Contact Kadetskaya Law Firm, LLC
If your group life insurance claim was denied because Evidence of Insurability was not approved, not submitted, or not properly processed, do not accept that denial without speaking to an attorney. These cases frequently involve employer or insurer administrative errors — and those errors can be the basis for full recovery of the death benefit.
Call (888) 510-2212 now!
Kadetskaya Law Firm, LLC
630 Freedom Business Center Dr, 3rd Floor
King of Prussia, PA 19406
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.
