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Aurelia W | I want to know if an insurance can refuse to play benefits because of exclusions in policy drugs were found? |
drugs were found in my sons body yet he was not a drug user the insurance com said they were hiring an independent investagator and I thought they would investagate his death which they didnt and only the medical investagators report. |
 |
 
Joe P
 |
I will start by saying sorry for your loss. Unfortunately insurance companies are not in the business to hand out money. They are an avenue to transfer risk. The cause of death does not need to be drug related. If the toxicology report comes back positive for substance abuse, the insurance company will most probably deny any claims.
If you are adamant about your son's drug use or lack there of, it is possible the levels came from outside influences. For example, anyone who enjoys poppy seed buns could show up positive for marijuana abuse. I would look into that. |
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Insurance Biz CT
 |
That's what exclusions means. I don't know what exclusion you are speaking of. Are they saying he committed suicide by overdosing on drugs? Are they saying his death is as a result of an illegal act? Explain further. |
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mbrcatz
 |
If the policy says they don't pay for drug use, then yes. I'm assuming we're talking about a life insurance policy here.
More likely, if the policy is less than 3 years old, they're reviewing the application, and reviewing medical history, to see if there was "material misrepresentation" on the application - ie, history of drug or alcohol abuse that was NOT disclosed on the application - in which case they can deny the claim. |
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Suzanne: YPA
|
Please accept my condolences for your loss. As a mother, I can only imagine what deep pain you're experiencing right now.
"Insurance Biz CT" is absolutely right -- there aren't enough details in your question to answer conclusively.
First of all, (and I do understand this is painful for you) the cause of death it quite important. If the level of drugs in his system was determined by the Medical Examiner's office to be lethal, then the insurer's denial is correct, since this exclusion is permitted.
Secondly, I assume you've checked the policy to confirm the exclusion is there? If it is not, the Company is wrong; if it is, then the exact cause of your son's death becomes vital.
Thirdly, you imply that perhaps your son didn't take these drugs willingly. Does the autopsy report support this? Was there any sign of a struggle? Any sign that he was forcably given drugs? If so, this is a possible angle for appeal.
Don't be alarmed by what appears to be a lack of investigation by the Company. All it is required to do (except in LA, where the death certificate is prima facia evidence) is obtain and review the ME's report confirming cause of death. The Company is not required to disprove the ME's findings in order to pay your claim -- the law regards this as the obligation of the beneficiary.
If you truely believe the insurer is incorrect about the cause of your son's death, you can send a complaint to the insurance commissioner's office in the state where the coverage was purchased. While the insurance commissioner's staff cannot adjudicate a question of fact (that is, the cause of death -- accidental overdose vs. homocide by overdose), it can look at the insurer's claim file and determine whether it made a fair determination based on all the evidence provided. This process is free. You can also contact an attorney, but unless the insurer's decision is blatently incorrect, most will decline taking such a case. |
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nurse ratchet
 |
mbrcatz is right, except for the period of incontestability is 2 years, not 3. |
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Mark Y
|
Sorry to hear that. I studied a bit about insurance policies but am not an expert. Certainly an exclusion is an exclusion. For life insurance exclusions generally are only valid for the 1st two years of the policy. War is an exception but I never heard of drugs as being an exception but my studies were 30 years ago.
If the exclusion is for death from illegal drugs and you can prove that illegal drugs were not the cause of death you should be able to engage a lawyer and get the company to pay. Good luck. |
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MTR
 |
If there is an exclusion in the policy related to drugs, then yes, they can deny coverage. However, you need to know exactly what drugs, and if there were reasons for "false positives", such as poppy seed muffins indicating herion usage.
Get a copy of the medical examiner's report, ask for a second set of tests, and take a look at the policy exclusions. If may cost you a little for the second tests, but it may be worth it.
If you feel the exclusion is not fair, talk to the insurance division in your state, they can help you either understand, or go to bat for you if necessary.
I'm sorry for your loss, hope it works out for you |
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ktlove
|
if its in the exclusions, then yes the can deny payment, the exclusions are there for a reason.
how would drugs get into his body if he didn't put them there?
you will need an awsome awsome awsome lawyer, and a great judge to get past exclusions. its in the wordings. you signed the contract.
insurance companies hire the best of the best, dirtiest of the dirtiest lawyers. |
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