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Accidental death policy. Coroner ruled death due to multiple trauma from Motorcycle accident. Can ins. co req. all med rec's?

Allentown, PA |

An insurance policy has an accidental death rider. If that person dies in such a way, can the writing insurance company require all prior medical records for that individual? Can they deny the claim? How are prior medical records relevant to a case where the coroner determined the death to be from multiple trauma due to mv accident? Or are they looking for reasons to deny the claim? Seems like they are looking for ammunition.

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Attorney answers 4

Best Answer
Posted

Every claim submitted to an insurance company goes to a claims examiner, who then "investigates" the claim to see if it is covered by the policy, which includes looking into whether any other party, including the insured, may share responsibility for the covered injury or damage. In the situation you've described above, the insurance company will want to know what caused the "accident" not just what caused the death, and if it truly was an "accident" and not reckless or negligent behavior on the part of the insured or anyone else. There may also be provisions in the policy that pertain to the insured's health, mental status and/or life expectancy at the time of the incident. Thus, the medical records may actually be relevant in some way. Of course, the other possibility is that it is simply a procedural requirement on the part of the insurance company to obtain medical records first and determine relevance later. This may be a cost-cutting measure to eliminate "judgment calls" early in the claims process.

IMPORTANT LEGAL NOTICE: Ms. Brown’s response to the question above is not legal advice and it does not create an attorney-client relationship. All of Ms. Brown’s responses to questions posted on AVVO are intended as general information based upon the facts stated in the question, and are provided for educational purposes of the public, not any specific individual. If you would like to obtain specific legal advice about this issue, please contact an attorney in your state. Ms. Brown is licensed to practice law in New York. If you would like to contact her directly for a legal consultation, you may do so by calling 718-878-6886 during regular business hours, or anytime by email at: marykatherinebrown@hotmail.com

Asker

Posted

Very clear and helpful. Thank You.

Mary Katherine Brown

Mary Katherine Brown

Posted

You are welcome!

Posted

Well, the insurance company has the right to review the records. I'm not sure exactly why they would want prior records but certainly the ER records if any would be important. Just because they are looking doesn't mean they will find any reason to deny the claim.

This response does not create an ongoing duty to respond to questions, nor does it form an attorney-client relationship, it is simply the educated opinion of the author. It should not be relied upon as legal advice. The response given is based upon the limited facts provided by the person asking the question. To the extent additional or different facts exist, the response might possibly change. The Answering Attorney is licensed to practice law only in the Commonwealth of Pennsylvania. Responses are based solely on Pennsylvania law unless stated otherwise.

Asker

Posted

Tnx. If the ins. co's request is denied, can they in-turn deny the claim?

Posted

Insurance companies are always looking for reasons to deny claims. But most likely, the insurer wants to make its own determination that the death was accidental.

Posted

Insurance companies typically look at prior records to see if they can somehow challenge the cause of death. The coroner's conclusion should be enough but if pushed, a judge would most likely allow them to look at prior related medical records. Usually, what the company can and cannot do are usually contained within the policy.

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