Misrepresentation accusations often lead to life insurance denials when insurers find false or omitted information in an application that they believe would have changed their decision to issue a policy. These life insurance denials usually occur after the insured passes away and the insurer conducts a deeper investigation, commonly referred to as “post-claim underwriting,” into the insured’s medical, personal, or financial history. Once misrepresentation accusations arise in the process, consulting a life insurance lawyer in California can be significant to assist beneficiaries with insurance claims that may result in denials.
What Is Misrepresentation in Life Insurance?
In life insurance, misrepresentation generally refers to false, incomplete, or misleading information provided by the insured during the application process. Even unintentional misstatements may be grounds for an insurer to rescind a policy if the misstatement is material, meaning it would have influenced the insurer’s decision to issue or underwrite the policy.
Some of the most common types of misrepresentation that can trigger a life insurance denial include:
- Failing to mention a diagnosis, prior treatment, or ongoing health issue like diabetes, heart disease, or cancer.
- Omitting information about tobacco or drug use, alcohol abuse, or participation in high-risk activities such as skydiving or scuba diving.
- Reporting incorrect income or job title, especially in policies that require financial justification for higher coverage amounts.
- Not disclosing medications that could reveal an underlying condition that wasn’t mentioned.
In many cases, applicants may not knowingly provide incorrect information. They might misunderstand a question, forget a past diagnosis, or fail to mention occasional recreational habits. Nonetheless, under California law, even these innocent mistakes can be used by an insurer to void the contract and deny a claim if the information is considered material.
How Misrepresentation Accusations Lead to a Life Insurance Denial
Misrepresentation accusations typically surface after a policyholder’s death, when the insurance company is reviewing the claim. If the insured passed away within the policy’s contestability period (usually the first two years), the insurer may conduct a more detailed investigation into the insured’s history. This process is what industry professionals call post-claim underwriting.
During post-claim underwriting, insurers will:
- Obtain full medical records from healthcare providers
- Review pharmacy and prescription history
- Examine public databases such as the Medical Information Bureau (MIB)
- Assess financial records, employment documentation, or tax filings
If any of these sources reveal information that was not disclosed or was misrepresented on the application, the insurer may issue a denial letter. Under California law, the insurer may then seek to rescind the policy, essentially treating it as if it never existed, and refund the premiums rather than pay the death benefit.
What Beneficiaries Should Do After a Life Insurance Denial
When you receive a denial based on alleged misrepresentation, take immediate steps to protect your claim:
- Do not accept a refund of premiums. Accepting a refund may weaken your ability to challenge the rescission of the policy.
- Request a copy of the denial letter and policy. These documents outline the basis for the denial and are essential for legal review.
- Gather supporting records. Medical documents, application drafts, email correspondence, and statements from the agent may help refute the insurer’s claim.
A legal review by a life insurance attorney can determine the best course of action based on the policy type, governing law, and available evidence.
Request and review the insurer’s file. An attorney can demand the full claim file, including the application, underwriting guidelines, internal communications, and any medical records the insurer used to support the denial. This allows your legal team to assess whether the alleged misrepresentation was actually material.
Compare the application with external records. A careful review may reveal that the so-called misrepresentation is based on outdated or incorrect medical records, vague application wording, or innocent inconsistencies. For example, a person may have reported “no” to a question about treatment for depression because they did not consider short-term grief counseling to qualify.
Build a factual timeline. Establishing a clear timeline helps challenge insurer assumptions. If the insured applied for coverage years before a diagnosis was made or before symptoms even appeared, the insurer’s denial may lack legal merit.
Identify governing laws. A life insurance attorney can determine whether your claim is governed by California law or ERISA, and ensure that all procedural requirements are met.
Individual life insurance policies are governed by California state law, including the Insurance Code provisions that define misrepresentation and concealment. In these cases, a beneficiary can file a case in state court to challenge the denial.
Group life insurance policies, on the other hand, offered through an employer are typically governed by federal law, specifically the Employee Retirement Income Security Act of 1974 (ERISA). Under ERISA, beneficiaries must usually exhaust administrative remedies, such as a written appeal, before filing a lawsuit in federal court. The rules for what evidence can be considered are more restrictive, and deadlines are critical.
Whether your claim is governed by state or federal law, insurers must demonstrate that the misrepresentation was material to their underwriting decision. But in practice, insurance companies often take a broad view of materiality, arguing that any inconsistency could have affected their risk assessment.
Need Legal Help for After Misrepresentation Accusations in Life Insurance?
Misrepresentation accusations are one of the most common and most aggressive tactics insurers use to deny life insurance claims. Whether the information was wrong, incomplete, or simply misunderstood, these denials should not go unchallenged. California law places the burden on insurers to prove that any misstatement was material, while federal law under ERISA sets strict procedures for group life claim appeals.
At the Law Offices of Kevin M. Zietz, PC, we have over 25 years of experience handling misrepresentation-based life insurance denials. We know how to compel insurers to prove that the misrepresentation was material and that they would have taken a different underwriting action had the information been disclosed.
If you’ve received a misrepresentation accusation and need guidance on how to deal with it, our life insurance lawyer can evaluate your case and help you fight back. To get started, call 818-981-9200 or contact us online to schedule your free consultation.
A portion of your pay is reduced from your paycheck by your employer. This money goes toward Social Security benefits, which you pay into for all the years you work and earn wages. While many people end up using their Social Security toward their eventual retirement, another benefit that comes from it is Social Security disability insurance.
Social Security disability insurance is in place in the event that you suffer a serious long-term or even permanent disability that prevents you from working. If you become disabled, you have the right to file a disability claim with the Social Security Administration or SSA to get monthly payments.
Unfortunately, although millions of people suffer from disabilities each year and apply for Social Security disability benefits, things are not always black and white. One thing that can happen is that you are denied benefits in spite of your legitimate disability status.
When Social Security Disability Benefits Claims are Denied
Each year, around 66 percent of all California residents applying for Social Security disability benefits have their claims denied by the SSA. If this happens to you, it’s no doubt a scary situation as you are unable to work and earn a living. It’s fair to wonder how you will be able to get by financially. However, if your application is denied, there are steps you can take to make an appeal. You can still end up getting disability benefits. One thing you can do is to contact a Los Angeles denied disability attorney for help.
Why Do Social Security Disability Claims Get Denied?
There are various reasons why your Social Security disability claim might be denied. First-time applications are often denied, but it’s important to know why this is the case as it can help you in the future.
If you are denied benefits, the SSA will send you a letter explaining the reasons behind the decision. There will also be steps in the letter that explain how you can appeal that decision.
The following includes the most common reasons why a Social Security disability claim is denied:
Insufficient medical evidence: The chief reason for a claim being denied is insufficient medical evidence. You must prove that you are unable to work for at least 12 months, which means you should include all the pertinent documentation, tests, treatments, and anything else relevant to your condition.
Substantial gain activity or SGA: If you earn more than the SGA, your application will be denied. Your income cannot be higher than the amount of benefits you would receive.
Neglecting to follow treatment plan: Not following the doctor’s treatment plan can result in a claim denial. The plan serves as proof that you are unable to work due to your condition.
Ignoring requests: Your claim can be denied if you ignore requests for additional documentation.
Refiling a claim: You can also be denied if you were previously denied and refiled a claim for benefits. You should appeal instead of filing a new claim.
Reconsideration of Denied Social Security Disability Claims
California recently instituted a reconsideration of denied Social Security disability claims. This policy means that claims that were previously denied will be re-reviewed for consideration. However, this only applies to individuals who have chronic or debilitating medical conditions such as terminal cancer.
Filing an Appeal of Denial of Your Claim
If your claim was denied and you do not have a chronic or debilitating medical condition, you can still appeal the decision. It’s important to know that it can take months or even years before your application is re-evaluated, but you can retain a Los Angeles disability lawyer to assist you. In some cases, you may even learn that your claim was denied simply due to a mistake you made on your application.
In most cases, you only need to deliver additional documentation to the SSA when you file your appeal. The best thing you can do is have legal counsel on your side. If you need a disability attorney Los Angeles has plenty of highly professional, experienced options for you. Having a denied disability attorney in Los Angeles can make a huge difference in the outcome of your appeal.
You will have to submit additional or even new medical evidence and a Residual Function Capacity or RFC form, which must be filled out by your doctor. It’s strong evidence that helps to support your disability claim.
There may also be a disability hearing where a judge will hear why you deserve Social Security disability benefits. Your attorney can help you here as well. You will also be required to answer questions posed by a medical expert.
If the denial of your claim is not overturned, the decision then goes to the Appeals Council and a new judge will review your case. This can lead to the previous decision being overturned.
If you are in California and have your Social Security disability benefits claim denied, you need the Law Office of Kevin M. Zietz on your side. You will have the opportunity to discuss your case with an experienced Los Angeles disability attorney and have a better chance during your appeal.
Long-term care (LTC) insurance covers the costs of nursing home and/or assisted living services. Under most long-term care policies, a person is eligible for benefits when they are not able to do at least two out of six “activities of daily living” without the assistance of a home health professional, or they suffer from dementia or other cognitive impairment. The activities of daily living are:
- Bathing.
- Caring for incontinence.
- Dressing.
- Eating.
- Toileting (getting on or off the toilet).
- Transferring (getting in or out of a bed or a chair).
LTC insurance is expensive. According to the Alzheimer’s Association, the estimated cost for end-of-life care in 2019 ranged between $233,000 and $367,000. Most health and disability insurance will not cover long-term care, but long-term care insurance will.
Long-term care insurance policies may have limits on how long or how much they will pay. Some policies will pay the costs of long-term care services for two to five years, while other insurance companies offer policies that will pay for a person’s long-term care costs for as long as they live, regardless of cost.
Unfortunately, in the ongoing effort to cut their costs, insurance companies routinely deny valid LTC insurance claims based on technical requirements in the policies. Insurance companies also deny LTC claims by disputing that a person’s medical condition requires the level of care covered by the LTC policy, or by suggesting that those seeking benefits are receiving more care than is necessary or have been placed in the wrong type of facility.
If you have questions about what your options are after an insurance company has denied a claim for LTC benefits, call attorney Kevin M. Zietz for a free consultation.
