Case study

Life claim denial reversed on appeal after APS review

A $500,000 term policy claim was denied during contestability for allegedly omitting hypertension treatment on the application. The beneficiary received a denial citing pharmacy records from a mail-order program not disclosed at purchase.

Key takeaway

Appeal denials with primary-source medical records—not just the beneficiary's summary.

Real-world claim scenario and documented outcome

Denial pattern tags

ContestabilityDocumentation Gap

Scenario

A $500,000 term policy claim was denied during contestability for allegedly omitting hypertension treatment on the application. The beneficiary received a denial citing pharmacy records from a mail-order program not disclosed at purchase.

Outcome

On appeal, the beneficiary supplied APS records showing the condition was diagnosed after policy issue and pharmacy records were for a different household member with a similar name. The carrier reversed the denial and paid face amount plus interest 38 days after appeal submission. Related playbook: /claims/guides/life-claim-delay-denial-guide.

Document checklist

Written contestability denial with cited pharmacy records
Attending physician statements showing diagnosis dates
Pharmacy records distinguishing household members
Application question and answer the underwriter relied on
Appeal submission confirmation

What this case teaches

3 editorial takeaways

Apply these documentation lessons from this case before filing a similar claim.

Appeal denials with primary-source medical records—not just the beneficiary's summary.
Challenge pharmacy matches that confuse household members or name variants.
Request the exact application question and answer the underwriter relied on.

Cross-check against related claim playbooks before you accept a settlement.

Related playbook: life claim delay denial guide

Cite this research

Insurhi. (2026). Life claim denial reversed on appeal after APS review. https://www.insurhi.com/claims/cases/9

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