Yes, a life insurance company may sometimes deny a claim because of the insured’s medical history—but the existence of a prior illness or medical condition does not automatically justify a denial.
These disputes usually arise when the insurer alleges that the insured failed to disclose, or incorrectly answered a question about, a medical condition on the life insurance application. The insurer may claim that it would not have issued the policy—or would have issued it on different terms—if it had known the insured’s complete medical history.
Whether the denial is valid depends on several factors, including:
- The wording of the application questions
- What the insured knew when completing the application
- Whether an answer was actually false or incomplete
- Whether the information was material to the insurer’s underwriting decision
- How the insurance agent recorded the answers
- How long the policy had been in effect
- The law governing the policy
- Whether the policy was privately purchased or obtained through an employer
Beneficiaries should not assume that a medical-history denial is final. Life insurance claim denials can often be challenged.
Why Do Life Insurance Companies Investigate Medical History After Death?
When a death occurs relatively soon after a life insurance policy was issued, the insurance company may conduct a contestability investigation.
During this investigation, the insurer may request:
- Medical records
- Prescription-drug histories
- Hospital and emergency-room records
- Primary-care records
- Specialist records
- Laboratory and diagnostic-test results
- Prior insurance applications
- Employment or disability records
- The insured’s original life insurance application
- Statements from physicians, family members, or the insurance agent
The insurer generally compares these materials with the answers provided on the application. If it discovers information that was not disclosed, it may allege a material misrepresentation and attempt to rescind the policy.
Rescission means that the insurer treats the policy as though it should not have been issued. Instead of paying the death benefit, the insurer may return some or all of the premiums.
What Is a Material Misrepresentation on a Life Insurance Application?
Not every incorrect answer permits an insurance company to deny a claim. The insurer will ordinarily need to establish that the incorrect or omitted information satisfied the legal standard for a material misrepresentation.
A fact may be considered material if truthful disclosure would have affected the insurer’s underwriting decision. For example, the insurer may argue that it would have:
- Refused to issue the policy
- Charged a higher premium
- Issued a smaller policy
- Delayed issuing coverage
- Required additional medical testing
- Excluded or limited certain coverage
- Offered a different type of policy
Under Florida Statute § 627.409, a misrepresentation, omission, concealment, or incorrect statement may prevent recovery if it was fraudulent or material to the insurer’s acceptance of the risk or if the insurer, acting in good faith, would have issued the policy differently had it known the true facts.
The precise standard varies by state. The policy language may also impose requirements that are more favorable to the insured than the minimum standard established by state law.
What Medical Conditions Commonly Lead to Life Insurance Claim Denials?
Insurers may investigate virtually any medical information that they believe should have been disclosed. Common subjects include:
- Heart disease
- High blood pressure
- Diabetes
- Cancer
- Kidney or liver disease
- Stroke history
- Mental-health treatment
- Depression or anxiety
- Substance-use treatment
- Sleep apnea
- Neurological disorders
- Chronic pain
- Prescription-drug use
- Tobacco or nicotine use
- Pending medical tests
- Recent hospitalizations
- Prior surgeries
- Abnormal laboratory results
- Undisclosed physicians or medical consultations
The presence of one of these conditions does not, by itself, establish that the claim should be denied. The insurer must consider the application’s actual questions, the insured’s answers, and the applicable law.
Can the Claim Be Denied If the Medical Condition Did Not Cause the Death?
Possibly. This is one of the most misunderstood issues in life insurance claim disputes.
Depending on the governing state law and policy language, the insurer may not have to prove that the undisclosed medical condition caused or contributed to the insured’s death. The insurer may instead argue that the information was material because it would have influenced the original decision to issue the policy.
For example, suppose an insured allegedly failed to disclose diabetes but later died in an automobile accident. The company may still contend that the undisclosed diabetes affected its underwriting decision, even though diabetes did not cause the death.
That does not necessarily make the denial valid. The beneficiary may still challenge whether:
- The application clearly asked about the condition
- The insured knew about the condition
- The answer was actually inaccurate
- The insurer followed its own underwriting rules
- The information would genuinely have changed the underwriting decision
- The agent was responsible for the incorrect answer
- The insurer already possessed or could have reviewed the information
- The contestability period had expired
The absence of a connection between the medical condition and the death may nevertheless be relevant, particularly under laws requiring a relationship between the alleged misrepresentation and the claimed loss.
What Is the Life Insurance Contestability Period?
Most life insurance policies contain an incontestability provision. It generally limits the insurer’s ability to challenge the validity of the policy after it has remained in force for a specified period—commonly two years during the insured’s lifetime.
Florida law requires life insurance contracts to become incontestable after the policy has been in force during the insured’s lifetime for two years from the date of issue, subject to limited exceptions such as nonpayment of premiums and certain disability or accidental-death benefits.
If the insured dies during the contestability period, the insurance company will frequently examine the application and medical records before deciding whether to pay the claim.
If the insured dies after the contestability period expires, the insurer’s ability to challenge the policy based on application statements may be significantly restricted. However, the exact outcome depends on the policy, governing law, alleged grounds for denial, and any applicable exceptions.
Does an Innocent Mistake Justify Denial?
It depends on the applicable law and the policy language.
Some beneficiaries understandably believe that the insurer must prove that the insured intentionally lied. That is not always true. In some jurisdictions, a materially incorrect answer may support rescission even if the mistake was unintentional.
A denial may still be contestable if the application question was unclear, the insured answered truthfully based on his or her knowledge, or the alleged omission would not actually have changed the insurer’s underwriting decision.
Important questions include:
- Was the insured ever formally diagnosed?
- Was the insured merely undergoing testing?
- Did a physician explain the diagnosis to the insured?
- Did the application ask about a specific time period?
- Did the question ask about diagnoses, symptoms, consultations, or treatment?
- Was the insured told that a condition had resolved?
- Did the insured reasonably misunderstand the question?
- Did the insurance agent complete or alter the application?
The difference between knowingly concealing a diagnosed illness and failing to disclose an unexplained symptom can be critical.
What If the Insurance Agent Completed the Application?
Many life insurance applications are completed electronically or with substantial assistance from an insurance agent. The agent may ask questions verbally, enter the answers, and instruct the applicant where to sign.
Disputes may arise when the agent:
- Failed to ask every application question
- Entered an inaccurate answer
- Minimized a disclosed medical condition
- Told the applicant that certain information was unnecessary
- Failed to record the applicant’s complete answer
- Submitted the application without allowing the applicant to review it
- Encouraged the applicant to answer “no” to speed up approval
The insurer may rely on the signed application and argue that the insured adopted every recorded answer. The beneficiary may respond with evidence concerning how the application was actually completed.
Relevant evidence may include emails, text messages, agent notes, recorded calls, application audit trails, electronic signatures, and testimony from people present during the application process.
Can a No-Medical-Exam Policy Be Denied for Medical History?
Yes. “No medical exam” does not necessarily mean “no medical questions” or “no medical investigation.”
A simplified-issue or accelerated-underwriting policy may be issued without a physical examination, but the application may still ask about diagnoses, prescriptions, physicians, hospitalizations, tobacco use, and pending tests.
The insurance company may also obtain information from third-party databases or request medical records after the insured’s death. A beneficiary should therefore review the actual application and policy instead of relying on advertising that described the coverage as requiring “no exam.”
Some policies provide limited benefits during an initial period or are issued as guaranteed-acceptance coverage. Those policies may operate differently, making the precise policy terms essential.
How Can a Beneficiary Challenge a Medical-History Denial?
A beneficiary should request and carefully examine the insurer’s complete basis for denial. Useful documents may include:
- The denial letter
- The complete policy and all riders
- The original application
- Any reinstatement application
- Amendments or supplemental questionnaires
- Medical authorizations
- The insurer’s underwriting file
- The medical records relied upon
- Prescription-history reports
- The insurer’s underwriting guidelines
- Communications involving the insurance agent
- Recorded telephone interviews
- The insurer’s internal claim notes
- Any premium-refund correspondence
A life insurance claims lawyer may investigate whether the insurer has proved each element required to rescind the policy. That investigation may involve comparing the medical records with the application, examining ambiguous questions, reviewing underwriting guidelines, and determining whether the supposedly undisclosed condition would really have changed the insurer’s decision.
What Should You Do After Receiving a Life Insurance Claim Denial?
If a claim has been denied because of medical history, consider taking the following steps:
- Read the entire denial letter. Identify every application answer and medical record the insurer relies upon.
- Request the policy and application. Do not assume that the insurer has accurately quoted the documents.
- Preserve communications with the agent. Save emails, text messages, notes, and the agent’s contact information.
- Do not speculate in writing. Casual explanations about what the insured “must have known” may later be used against the claim.
- Determine whether the policy was employer-sponsored. Employer-provided coverage may be governed by the Employee Retirement Income Security Act, commonly known as ERISA.
- Identify all deadlines. An administrative appeal or lawsuit may be subject to strict time limits.
- Consult a life insurance claims lawyer. Legal review may reveal factual, contractual, or underwriting defenses that are not apparent from the denial letter.
Are Employer-Provided Life Insurance Claims Different?
They can be.
Many group life insurance policies obtained through private employment are governed by ERISA. An ERISA claim may involve mandatory administrative procedures, federal law, plan documents, and deadlines different from those that apply to an individually purchased policy.
A beneficiary who receives an adverse benefit determination ordinarily has at least 180 days to submit an administrative appeal under the federal benefit-claims regulations. However, the plan and denial letter should be reviewed immediately because the appeal record can become critically important in later litigation.
A beneficiary should avoid submitting a short, unsupported appeal without first understanding the insurer’s allegations and the available evidence.
Frequently Asked Questions About Medical-History Denials
Can a life insurance company obtain the insured’s medical records after death?
An insurer may seek medical records during its claim investigation, often relying on an authorization provided with the claim forms or insurance application. The scope and enforceability of the authorization can depend on applicable law and the documents involved.
Can the insurer deny a claim for an undisclosed prescription?
It may attempt to do so if the prescription relates to an application question and the insurer claims the information was material. However, a prescription alone does not always establish that the insured had a particular diagnosis, knew of a condition, or answered the application incorrectly.
Can the insurer deny the claim because the insured forgot a doctor’s visit?
Not automatically. The wording of the question, the reason for the visit, the insured’s knowledge, and the materiality of the information must be evaluated.
What if the doctor’s records contain an incorrect diagnosis?
Medical records are not always accurate. They may contain coding errors, copied-forward histories, preliminary diagnoses, or conditions never communicated to the patient. A beneficiary may challenge the insurer’s reliance on inaccurate or misleading entries.
What happens to the premiums if the policy is rescinded?
An insurer that rescinds a policy will commonly offer to return premiums instead of paying the death benefit. Accepting or negotiating a premium-refund check may raise legal issues, so a beneficiary should consider obtaining advice before doing so.
How long does a beneficiary have to challenge a denial?
Deadlines vary based on the governing law, policy language, type of coverage, and claim procedures. An ERISA plan may also require an administrative appeal before a lawsuit can be filed. Prompt review is important.
A Medical-History Denial Is Not Necessarily the End of the Claim
Life insurance companies may use medical records to investigate whether an insured provided complete and accurate information. But discovering a prior medical condition does not automatically give the company the right to avoid paying the death benefit.
The insurer may still need to prove that the application contained an incorrect statement, that the information was material, that the applicable contestability rules permit the challenge, and that rescission is authorized by the policy and governing law.
Beneficiaries facing a denial should obtain the policy, application, medical records, underwriting materials, and claim file before accepting the insurer’s conclusion.
Speak With a Life Insurance Claim Denial Lawyer
If a life insurance company denied your claim because of the insured’s medical history, alleged nondisclosure, or an application misrepresentation, J.P. Gonzalez-Sirgo, P.A. can review the denial and explain your legal options.
Our firm represents life insurance beneficiaries in disputes involving contestability investigations, application misrepresentations, policy rescission, delayed claims, ERISA coverage, and other denied life insurance benefits.
Contact J.P. Gonzalez-Sirgo, P.A. to discuss your life insurance claim. The facts, policy language, and applicable law should be carefully evaluated before you accept the insurance company’s decision.
Have you or someone you know been denied a life insurance claim? Contact Florida Life Insurance Claims Lawyer J.P. Gonzalez-Sirgo by dialing his direct number at (786) 272-5841, calling the main office at (305) 461-1095, or Toll Free at 1 (866) 71-CLAIM or email Miami Attorney Gonzalez-Sirgo directly at jp@yourattorneys.com or by text at (305) 929-8935.
This article is for informational purposes only and does not constitute legal advice.
