How Diabetes & High Blood Pressure Effect Life Insurance Death Claims

$500,000 claim denied, appealed, and paid!

We’ve written a lot about death claims denied for single-health problems such as cancer or depression alone. But more often, we see claims denied where the insured had multiple health conditions. Here we look at one claim we successfully appealed in which the insured had both diabetes and high blood pressure.

How are diabetes and high blood pressure related?

Some health problems are separate and independent of one another. Others affect each other and worsen one another.

According to the American Diabetes Association, two-thirds of Americans with Type 2 diabetes also have high blood pressure. Both show a correlation with diet: a diet high in fat, sodium, and sugar increases the likelihood of developing one or both of these conditions.

Unlike Type 2 Diabetes—which has noticeable symptoms such as increased hunger and thirst, frequent urination, severe headaches, and fatigue—high blood pressure is known as a “silent killer,” because it does not have outward symptoms. Yet if it goes untreated, the consequences are far more serious.

High blood pressure causes the heart to work overtime, and can lead to inflammation of the heart and blood vessels. It is associated with heart disease, heart attack, and a higher risk of stroke.

Diabetics must be particularly careful about regulating high blood pressure, as this condition can increase the risk of other complications, to which diabetics are already susceptible, such as kidney disease and retinopathy, which causes blindness.

Both diabetes and high blood pressure, however, can be regulated with diet, exercise, and medication. People can take responsibility to stabilize and even improve their conditions, which makes a significant difference for determining their eligibility for life insurance and eventually for the payment of a claim.

How do life insurance companies determine scores for people with multiple conditions?

When someone applies for a life insurance policy, an underwriter evaluates the insured’s health conditions. He or she will use a point system of debits and credits to determine the insurability of the applicant.

For example, someone with high blood pressure may get debited 50 points from an underwriter. Conversely, someone with good blood pressure may be credited 50 points. The more points one accumulates from an underwriter, the more expensive the policy premium. In cases where an applicant’s points exceed a threshold, say 250 points, the applicant will be declined for coverage.

In situations where an applicant has multiple health problems, such as high blood pressure and diabetes, their chance of being denied coverage is greater than if they only had one condition or the other.

The process of underwriting medical conditions is guided by the insurance company’s underwriting guide. The underwriting guide is a book that addresses how an underwriter should treat medical conditions when determining whether to offer a policy, decline coverage, or how much premium to charge for a policy. It’s a very comprehensive and detailed book.

How do life insurance companies determine death claims?

The life insurance underwriting process is a critical part of death claim investigations.

When a death claim is made by the beneficiary, the insurance company will re-evaluate the underwriting of the policy. The insurer will make a more aggressive effort to obtain all medical records of the deceased. They will then use the underwriting guide, with its debits and credits directives, to determine if the policy they issued is exactly equal to the policy they now believe should have been issued.

In simpler terms, the insurer will look for reasons to deny the claim, based on the debits and credits system in their underwriting guide, after the person has died.

Sound fair? It’s not.

For more than any other reason, death claims are denied for medical history the insured didn’t disclose on their application. Insurance companies put-out great effort to find medical conditions or treatments in the person’s past that they then use as the basis to deny claims.

[An important note: there are a lot of reasons that medical conditions and treatments are left off of life insurance applications, and not all are intentional. It’s only when an applicant intentionally tries to hide medical problems that claims should be denied.]

A denied death claim should be evaluated and appealed by someone who knows both underwriting and claims procedures, and who can demonstrate when a omission was not intentional. While attorneys are often helpful, legal fees can be prohibitive, and many attorneys are not experts in insurance underwriting and claims procedures, as insurance professionals are.

The Center for Life Insurance Disputes knows these specific procedures, and it’s with the life insurance company’s own guidebook that we are able to overturn a denied claim.

How to appeal a death claim for $500,000

We successfully appealed a $500,000.00 death benefit that had been denied because the insured didn’t disclose his diabetes on the original application.

This insured also had high blood pressure, which he disclosed on his application. As we investigated, it became clear that the claim investigation acted solely on the fact that the insured had diabetes, rather than evaluating the severity of the diabetes as it would be described in the underwriting manual.

Our medical team reviewed glucose test results, treatment, and trends over the last year of the insured’s life. They also noted other entries in the medical record that we knew would be important to the debit and credit system that a life insurance underwriter uses.

Once we had evaluated the medical history and did a debit and credit underwriting review, we were able to determine how much insurance, and at what rate, the insurance company would have based their offer if they had known of the diabetes.

This denied claim—on which the insurer said it would not pay a single dime—has now been over-turned and paid.

Why a life insurance expert is best for appealing a denied claim

Although failing to disclose a preexisting medical condition might seem like it would result in the automatic denial of the claim, it depends on the condition, its severity, and the insured’s ability to manage it.

We could have written a foul-worded letter accosting the insurance company, but instead, we used logic to show the insurance company that, based on their own guide, they should pay the claim. This strategy is so much more effective than hiring a lawyer to file a lawsuit.

When any creature feels threatened, its instinct is to defend itself. It’s absolutely the same when a life insurer is served with a lawsuit. The opportunity for resolving the dispute is gone, legal fees begin, and a fight ensues.

Because of the way we approached this claim dispute—with knowledge of the insurance company’s policies and understanding of the medical conditions at hand—this denied claim was successfully appealed and paid in only four months, with zero legal fees.

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