Investigation?

Posted: Sat Feb 20, 2010 01:37 am Post Subject:

Would that sort of situation warrant an investigation?

The death certificate reads as brain injury as the main cause of death

but a heart attack(which happened during surgery) as the cause leading up to the death.

I ask this because i've had a claim going on for a month, and they still say it's being 'investigated' that's the only reason in my head that it would take this

Posted: Sat Feb 20, 2010 03:14 am Post Subject:

You know on the death cert, where it says chain of events leading to death? The 'immediate cause of death' was Anoxic Brain Injury' There were no brain injuries prior, the person had complications during the surgery and was left in a coma. After a few days they determined there wasn't any brain activity.

The original beneficiary form on file was to be paid to her god mother who had been deceased for years, with her children as the contingent because they we're too young. She updated them with her two sons as the primary since they we're now old enough.

Posted: Sat Feb 20, 2010 12:32 pm Post Subject:

so it went from 'god mother' to her own two sons? How old are these son's and were they in her life?

Posted: Sat Feb 20, 2010 02:52 pm Post Subject:

Are you sure that the investigation has anything to do with the fact of "change of beneficiary?" Does the insurance company really care who they have to pay the claim to? The question I have is, was the policy in it's contestability period (was the policy issued within the last 2 years)? If the insurance company is investigating, don't you think they would care about their bottom line and not who they have to pay the claim to. As long as the claim form was dated (before death), witnessed and properly filled out why would the insurance company worry about our U.S. Postal service's poor effort (mail time) of delivery the claim form?

Now comes the issue of who are you "Tigerwoo" to the son's? What is your relationship to them?

Posted: Sat Feb 20, 2010 05:32 pm Post Subject:

Yes @ Lori. She had been with her job for almost 15 years at the time she got the job, her sons were minors, so she didn't have them listed as her primary beneficiaries. It was her god mother, with the boys as contingent. Her god mother had been passed away and she just never got around to updating them, so she updated them prior to her first major surgery which she just so happen didn't happen to survive. And her children are grown 23 and 25 and they still stayed with her. Her only kids, they are the ones that had to sign the papers to let the hospital take their mother off life support.

And @ Mr. Vice President. I'm just their cousin. They are going through alot, with bills, a funeral home who wants payment. and just the stress of losing their mother. So i've just been asking as many questions as i can.

The insurance was through her employer, so their case worker is just saying since it's alot of money it's taking some time. They have already started the process to collect on her pension and retirement and her final wages, it's just the life insurance company that seems to be taking the longest.

Posted: Sat Feb 20, 2010 11:05 pm Post Subject:

I would call the insurance company direct...if it's going to go over 30 days, I'd ask for a 'written' explaination "why"? What 'exactly' is the problem...there is no one contesting this...no arguement about the policy being enforce at the time of death, no arguement about the beneficarys, so what is the issue? If they cannot get an answer, my next call would be to your states dept of insurance and file a complaint. "IF" they have exceed the allowed time to pay the claim or advise (in writing) that they require more time for an investigation, and reveal the reason for it...I don't know what the hold up would be...

This 'case worker' is that someone in your Aunts employers HR office or the actual insurance carrier?

Posted: Mon Feb 22, 2010 04:07 am Post Subject:

Unless the policy is an "Accidental Death" benefit contract rather than honest-to-goodness life insurance, an "investigation" is likely unwarranted. [If the policy is an Accidental Death Benefit contract, you have a different problem. "Anoxic Brain Injury" is not an "accident" in most cases, and would not entitle anyone to receive a death benefit. It results from a loss of blood flow, hence oxygen, to the brain. That could be from a blood clot, a ruptured aneurism, or any number of non-accidental causes that would prevent blood/oxygen from getting to the brain, like a "heart attack" as you mention. On the other hand, if a person was clubbed on the head, resulting in a hematoma that blocked an artery, that would be an accidental cause.]

But if we're talking about a true life insurance policy, if there is no assertion of the owner's mental defect (insane, Alzheimer's, dementia, legally incapable of making decisions) or some form of coercion, a beneficiary statement redesignating beneficiaries must be accepted if it can be verified that the owner of the policy is the person who signed the change request.

Now, if I've read the posts correctly, the original primary beneficiary predeceased the insured. The two [minor] children had been named as contingent beneficiaries, but are now adults (eliminates any discussion of the "contestability" of the policy, it is incontestable). The change of beneficiary was intended only to make the same two [contingent] beneficiaries primary.

Assuming that's true, the change of beneficiary request is a moot issue. Although it would serve to clarify the insured's pre-death desire (whether by one day or one year), it would not have been necessary. If the primary beneficiary predeceases the insured, and there is a named contingent (or two, in this case), the contingent is automatically elevated to the status of primary unless, and until, a change of beneficiary makes someone else primary.

That is not being asserted here. The insurer appears to be dragging its feet for no apparent reason. Time to make two phone calls:

#1 goes to the most senior claims supervisor you can get to LIVE on the phone -- don't settle for voice mail. The first question to ask is: "Do you understand what 'UNFAIR CLAIMS PRACTICES' means?" The second question to ask is: "Will it help move the claim along after I call the Department of Insurance and file a complaint about UNFAIR CLAIMS PRACTICES?"

The claims supervisor should fully understand those two questions and indicate that the matter will be resolved quickly. If you get anything short of the matter will be taken care of in the next 24-48 hours, then it's time to make phone call #2.

That one goes to the Department of Insurance (or whatever the insurance regulator is in your state). You want to make a complaint about UNFAIR CLAIMS PRACTICES. Nearly all states have adopted the "Model Unfair Claims Practices" bill created by the NAIC, and one of the prohibitions in that bill is against delaying the payment of a claim when liability has been established. That would be the basis of your complaint . . . Person A died, the insurance company has received a proper claim and death certificate, and liability to pay the death claim should have been determined quickly.

But not if the policy is an Accidental Death Benefit contract. An insurer would have the legal right to perform an autopsy at its own expense to determine cause of death if there is any doubt as to whether it was accidental or medical (non-accidental).

Good luck, and keep us updated.