Driving Intoxicated, Insurance will not pay AD&D?

jbanda

We provide STD, LTD, AD&D and Life insurance to our employees(Company pays for benefit), recently we had our first claim with our insurance carrier for AD&D ($10000), employee died in a car accident, and there is a good possibility that he might of been driving under the influence of alcohol (possibly over the legal limit), when we submited a claim, our insurance is asking for an autopsy, when I question this, they told me that they are basing this on the following exclusion: "We will not pay benefits if the loss results directly or indirectly from the use of any drug, unless you use it as prescribed by a doctor".

Does this sound correct to you'll? anybody experienced anything like this?,

thanks in advance for your response, we are in the state of texas.

Theresa Gegen TX

Under the law, the insurance company, when they get a claim for benefits, has a right to investigate the claim to determine its merit. I have litigated an AD&D policy case where the autopsy (or cornor's inquiry) was a key piece of evidence. (That case involved whether a death was by suicide or accidental).

Whether or not that exclusion applys to lawful substances, like alcohol, is a seperate legal question that would need to be researched in detail.

The beneficiary of the policy needs to follow the terms of the erisa plan strickly and put forth any evidence they have before the decision maker. If it isnot put forth now, they can be precluded from bringing it up later.

Good Luck!