Denied Insurance Claims

Heading 2

Insurance denial letters are very emotional and disappointing for consumers. Upon receiving a denial letter, many consumers become upset, angry, and confused. Many people feel betrayed because they paid their insurance premiums for years only to be denied help when an unexpected loss or injury occurs. If your insurance claim was denied, you are not alone.

Many legitimate insurance claims are denied every day, and if the denials are not challenged within a short timeframe, you may forever lose the right to challenge them. If the denial was by your own insurance company, you typically must file a lawsuit within 2 years of the denial. While if the denial was by another person’s insurance company, you must sue that person (not their insurance company) within 2 years from the date of the incident that caused injury (not the date of denial). Many people are unsure of what to do when their claim is denied, and many people end up doing nothing.

By law, insurance companies are required to give you at least one reason for denying your claim. Although the reason given may not be the only basis for denying the claim, it is a helpful starting point for determining what to do next. The following are some reasons that insurance claims may be denied.

Inactive Policy

Unfortunately, if the policy was not in effect at the time of the incident, there is virtually nothing that can be done to reverse the denial.

Uncovered Person

Often claims are denied because the person who caused the injury or damage is not covered by the insurance policy. Challenging these claim denials require a careful analysis of the policy itself along with the law. For example, if a claim was denied because a person was not a “resident” of your home, you may be able to reverse that decision by proving that the person was in fact a resident as defined by the policy and the law.

Many times, a dispute about whether a person is covered or not may be resolved by providing proper documents. However, if that does not work, a lawsuit must be filed.

False statements

Many insurance claims are denied because someone allegedly made a false statement to the insurance company, either during the claim process or at some earlier time. While some false statement are valid reasons for denying claims, not all false statements can legally serve as valid reasons for denials. More bluntly, even if you lied, the insurance company may still have to pay.

If the basis for denial is a false statement, you must immediately seek legal representation because a false statement is not only a basis for a claim denial, it is also a crime.

Uncovered perils

Your insurance policy will have a section telling you what is covered. If your situation does not fall within the things that are covered, your claim will be denied. Therefore, if you do not have coverage for flooding, your claim will be denied if your home is damaged by a flood. In such a situation, the dispute will be about what exactly constitutes a “flood” and were there other damages caused by something other than a “flood”, e.g., wind.

If lack of coverage is the basis of the denial, it is very unlikely that the denial will be reversed without a lawsuit.

Exclusions

If you only read the coverage section of your insurance policy, you may be in big trouble. Your policy will contain a section that explains what is covered. It will also have a section explaining what is not covered, i.e. the exclusions. The exclusions are very important because they trump the main coverage.

If a claim is denied based on an exclusion, a careful analysis of the policy definitions and the law will be very important. If an exclusion is the basis of a denial, it is very unlikely that the denial will be reversed without a lawsuit.

Failure to follow procedure

Your insurance policy sets out a number of actions that you need to take for there to be coverage. If you do not do the required actions, your claim may be denied. Fortunately, these types of denials are generally easy to reverse if you are able to come into compliance with the terms of your policy.

Failure to cooperate

Your insurance policy requires you to cooperate during the claims process. Therefore, if you do not comply with an adjuster’s request, your claim may be denied. Fortunately, these types of denials are generally easy to reverse if you are able to come into compliance with the requests of the adjuster.

Amendments and endorsement

These are changes to the policy, which are attached to the policy as separate documents. They are very difficult to read and understand, but they are very important because they may completely change the meaning of the policy.  A policy amendment may look like the following:

You may ask, “Why didn’t the insurance company simply make the changes before giving me the policy?” However, that would be a question for your insurance company or the State Legislature.

FREE CONSULTATION

Insurance law is a very complicated subject matter and each case requires a careful legal analysis that cannot be given effectively in a blog post. If you have specific questions about your insurance claim denial or would like us to take your case, please complete the form below for a free consultation with an attorney.