Ad&D claim: waiting for decision

[quez]

So I'm worried I may be denied bc my dad's blood alcohol level was very high ( no exclusion for alcohol UNLESS DRIVING btw)

The other reason is this from the policy:
(q) an accident occurring (i) while the Insured Employee is not engaged in an
Occupational Activity, or (ii) while the Insured Member is not engaged in a
Sanctioned Activity

Occupational activity and sanctioned activities are not defined. My dad was a real estate agent ( no set work hours and even a phone call from a prospective client or him cold calling could be considered work right? the accident occurred in a bar at 1am ( he slipped and cracked his skull, death was ruled accidental and not from natural causes as per autopsy)

What u guys think?

 

[alinajj]

@quez I don't know anything about these policies (I do commercial auto claims.) I feel like your fears are justified. Being at a bar at 1 AM does not sound like an occupational activity, unfortunately. Even if he worked via the phone conducting his real estate affairs, I don't think you could convince an adjuster that he was doing so at a bar at 1 AM.

 

[quez]

@alinajj You could argue was taking clients out to dinner etc. Technically just taking work related phone calls or talking to random who are interested in doing business could qualify. Thing is the terms they use a very vague and undefined. If he was a construction worker then clearly being at a bar isn't working.

 

[trustinggod]

@quez The insurance company isn't stupid and your argument won't work.

 

[alinajj]

@quez You would have to prove that he was performing occupational duties. That means you would have to have a client corroborate that he was at the bar doing such. A claim that he was working at a bar at 1 AM performing realtor duties has to be substantiated. While I do not know anything about these policies, any claim for any type of insurance requires proof. You will have the burden of proof.

 

[quez]

@alinajj Curious do you have experience in these matters ?

 

[alinajj]

@quez Yes, I am liability claims adjuster for an insurance company. Insurance claims are all the same in the fact that a claim requires evidence and must be proven.

If you want any chance of proving your claim, you may want to look at your dad's phone log and see if there are any phone calls to potential clients around the time of loss. If you have access to his emails, maybe check there, too. See if a client met him at this bar.

I will say that even if you could prove your dad was at the bar speaking to a client, the policy issuer would still likely deny the claim as he was walking home. I think the odds of you proving such a claim are nearly 0%.

You could also try to file the claim and see what their adjuster says?

 

[quez]

@bri1990 That's from the exclusions section.

 

[bri1990]

@quez It's unclear what section of the policy you are quoting. What is section (q) part of? Covered accidents or exclusions?

 

[bri1990]

@quez So, the AD&D only covers accidents while at work. Looks like you can't collect.

 

[quez]

@bri1990 I guess it means, if he was say sky diving that's not an "occupational activity"

 

[bri1990]

@quez It means if he was drinking at a bar at 1am that's not an occupational activity.

 

[quez]

@bri1990 Could also mean he's covered bc he wasn't skydiving or bungee jumping.

 

[quez]

@bri1990 Yes, but as I say it's via his employer ( a real estate board, a policy from a major insurance co) and that's a 24/7 job where you are constantly out and about ( if you work hard). I know for a fact he had many phone calls with friends that night, well what if his friend claims he's looking to sell his home etc? That job you work from anywhere and everywhere with cell phone service.

 

[jayparis]

@quez That's a stretch too far.

 

[bioleap]

@quez Those kinds of carriers don’t fuck around with those policies.

Very clearly the death doesn’t qualify.

I’d say that if you keep pushing it tows fraud, but it’s such an absurdly childish and wild assertion that I’m doubtful they will humor it at all.

 

[quez]

Update: good news they are paying out the claim...I wasn't expecting to get paid after I consulted with a lawyer. His opinion was they would argue he wasn't working when died.