Strategies to Overcome a Carrier’s Denial of a Life Insurance Claim

J.P. Gonzalez-Sirgo
Founder of J.P. Gonzalez-Sirgo, P.A.

Beneficiaries of life insurance policies often depend on prompt settlement of their claim to continue paying monthly household expenses.  Since life insurance benefits might constitute a critical component of divorce settlements, retirement strategies, and estate plans, insurers that stonewall, lowball, and deny claims can cause enormous hardships for surviving beneficiaries.  Some beneficiaries who receive a denial letter feel that they have no real chance of overcoming an insurance carrier’s refusal to pay benefits under the policy.  However, many beneficiaries do successfully challenge an insurance company’s denial of death benefits especially when assisted by an experienced life insurance claim lawyer. 

One of the most common tactics used by a life insurance carrier to deny a claim involves exploiting misrepresentations in the policy application.  If a claim is denied based on false or misleading information in the policy application, an insurance claims lawyer might use some of the following strategies to challenge a denial based on inaccurate or omitted information in the application depending on state law, policy language, and the surrounding circumstances.

Inadvertent Error Rather Than Intentional Misrepresentation

Although a claim can legitimately be denied even if false information on an application resulted from an honest mistake, an unintentional error might provide a defense to allegations of fraud in the application process.  Situations that might justify payment of a death benefit despite an innocent misrepresentation depending on state law include the following:

  • A language barrier prevented the insured from understanding the policy.
  • The agent caused the misrepresentation by inaccurately providing policy information or failing to input accurate information provided by the insured.
  • Ignorance of a factual circumstance or the significance of such a fact might excuse an inadvertent misrepresentation.
  • The insured suffered from a mental or emotional disability.

Because state law will dictate the acceptable grounds for excusing an unintentional misrepresentation, beneficiaries should seek prompt legal advice if they are denied a death benefit based on the alleged failure of an insured to accurately complete the policy application.

Misrepresented Facts Not Material

If you have recently completed an insurance application, you might recall that the insurer asked for lots of background information that would seem to have little connection to the risk undertaken by the insurer.  If every accidental oversight or inaccuracy in a policy application justified automatic denial of benefits, insurers would have an incentive to request a ridiculous amount of marginally relevant to entirely irrelevant information with the goal of eliciting accidental mistakes by the insured.  False information disclosed during the application process does not justify a policy denial unless it is “material”.  Generally, material facts are those that would affect the insurer’s decision to issue a policy, the policy limit, the amount of the premium, or other terms.  Information will not bar coverage if it is trivial or minor even if the personal or medical information is clearly omitted or false.

Divergent Underwriting Standards

Insurance carriers frequently modify their underwriting process when issuing a policy as opposed to paying a claim.  Put another way, personal information and medical facts that were ignored during the initial process of underwriting suddenly are elevated to vital factual information when a claim is made by beneficiaries. Successfully contesting a policy denial based on misrepresentations in a policy necessitates a careful analysis of the standards used when underwriting the policy.  If the insurer asserts that false or undisclosed information that was not given much attention when issuing a policy was the basis for denying the claim, this suggests that the denial is based on financial interests rather than objective criteria.  

Waiver

If the insurance company had knowledge of facts that should have put the insurer on notice of the false or inaccurate information, this might create a duty to inquire further.  When the insurance company ignores information in this situation, the insurance company might be deemed to waive its ability to rely on the non-disclosure or misrepresentation as a basis to deny coverage.

If you are the beneficiary of a life insurance policy, there are tactics that can increase the probability you will be able to overcome a denial of death benefits.  Miami life insurance attorney J.P. Gonzalez-Sirgo represents policyholders and beneficiaries in Miami and throughout Florida. The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations.  No Recovery, No Lawyer Fees.  Call 305-461-1095 or Toll Free 1-866-71-CLAIM.

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