When a life insurance claim is filed, beneficiaries expect timely payment. While many claims are paid without issue, others trigger a detailed investigation before any decision is made. Insurers are permitted to conduct claim reviews, but they are also financially motivated to find reasons to delay or deny payment. Understanding how these investigations are conducted reveals why legitimate claims may become the subject of scrutiny and dispute.

Initial Claim Intake and Administrative Review

The claims process typically begins when a beneficiary submits a death certificate, claim form, and any required documentation. At this stage, the insurer performs a basic administrative review to confirm that the policy was active, the premiums were current, and the beneficiary designation is clear.

If the documentation is complete and the death does not raise concern, the claim may proceed without further review. However, if the death occurred during the contestability period, involved unusual circumstances, or presented any inconsistencies, the claim is routed to a more intensive investigative process.

Triggering Factors for a Full Investigation

Claims are flagged for further investigation based on several criteria:

  • The death occurred within two years of policy issuance or reinstatement

  • The insured had multiple policies or recently increased coverage

  • The cause of death was accidental, violent, or medically ambiguous

  • The policy contains a relevant exclusion

  • The beneficiary designation changed shortly before death

  • The death occurred outside the United States

  • The documents submitted are inconsistent or incomplete

When one or more of these factors is present, the claim is referred to the insurer’s claims investigation unit or special investigations department.

Use of Internal Databases and Third-Party Sources

Insurance companies often review the original application for accuracy, comparing it against multiple sources:

  • MIB (Medical Information Bureau) records
    These records may reveal prior insurance applications, flagged diagnoses, or inconsistencies across applications.

  • Pharmacy benefit databases
    These track prescription drug histories and may expose undisclosed medications or conditions.

  • Credit and financial reports
    These may be used to assess motive or identify potential red flags in beneficiary selection or coverage levels.

  • Public records and social media
    In some cases, investigators review obituaries, court records, or online activity related to the decedent or claimant.

This process is particularly aggressive during the contestability period, when insurers can void a policy for misrepresentation.

Requesting Medical Records and Coroner Reports

For deaths involving medical complications or alleged misstatements on the application, the insurer will request:

  • Attending physician statements

  • Hospital admission summaries

  • Diagnostic test results

  • Autopsy reports

  • Toxicology screens

  • EMS reports and police investigations

Delays often occur while the insurer waits for these records to be produced. In some cases, the insurer may require the claimant to sign broad release forms to access the decedent’s entire medical history.

Reviewing the Beneficiary Structure

Insurers also verify whether the beneficiary designation was valid, properly documented, and consistent with policy terms. If the designation was recently changed, they may investigate whether the change was properly executed or subject to undue influence.

In cases involving minor children, trusts, or conflicting claimants, the insurer may seek clarification through legal review or file an interpleader action to have a court determine who is entitled to the proceeds.

Delays Under the Guise of Investigation

While insurers are allowed to conduct reasonable reviews, there is a legal distinction between valid investigation and improper delay. If the insurer fails to communicate, requests redundant documentation, or extends its review without cause, it may be acting in bad faith. Some delays function as constructive denials, placing financial pressure on beneficiaries who are unfamiliar with their rights.

Conclusion

Life insurance companies use a combination of administrative review, data analysis, medical records, and legal scrutiny when investigating claims. These investigations are often presented as routine but can mask efforts to avoid payment. Beneficiaries should be aware of the process, understand what information insurers rely upon, and recognize when a claim has moved beyond legitimate review into territory that may require legal challenge. To learn about life insurance claim denials visit The Lassen Law Firm website.