Navigating & Fighting Insurance Claim Denials: Steps To Take and When To Seek Legal Help

Aside from getting medical attention, the first thing to cross your mind after an accident is typically the cost. Accidents can cause damage to their victims and the liable parties. For this reason, the importance of having an insurance policy is often stressed. Insurance exists to help lower costs via covering most expenses and damages.

Filing an insurance claim like a car insurance claim against the liable party’s insurer is typically one of the first things you do after an accident. Insurance companies usually settle disputes – the typical personal injury claim doesn’t go to trial. Everything doesn’t always go as planned, though. It is frustrating when you have your insurance claim denied.

This article will explain what to do in the event of an insurance claim denial and common reasons an insurance adjuster may deny your claim. Knowing the common reasons for a denied claim can help you to take the right steps towards recovering financial compensation for your injuries.

Hiring an experienced accident lawyer to represent you after an accident can maximize the compensation you receive after an accident. If you want to restore your quality of life in the best way possible after an accident, navigating the claims system with legal assistance is the best way to go about it.

Common Reasons Insurance Companies Deny Claims

So, the insurance company denied your claim and now you’re wondering why. The following are common reasons why insurance claims are denied after accidents:

Coverage Has Lapsed

Claims will be denied by insurance companies when they determine that insurance coverage has lapsed. Insurance coverage can lapse for a few different reasons: the insurance carrier doesn’t exist anymore, the policy was unilaterally canceled by the insurer, or the premiums haven’t been paid on time. Claims will only be approved by insurance companies when valid, up-to-date policies exist.

Valid Coverage Doesn’t Exist

You will only be paid for an injury claim or property damage claim if a valid insurance policy is in place. For example, let’s say you slip and fall in a store and break a bone. After your accident, the store’s owner gives you the insurance company’s contact information.

When you contact that insurer, however, they say no record exists of any policy covering that store. This happened because the owner just opened a new store and didn’t properly change his insurance policy. Because of this, the coverage is invalid and your claim will be denied.

Driver Exclusions

Every vehicle that’s registered in California needs to be covered by valid insurance. However, just because there’s valid insurance doesn’t mean everyone driving that vehicle is covered.

Insurance policies often contain clauses of driver exclusion. This means a legitimate policy exists, yet some drivers aren’t covered. So, insurance carriers can issue a denial during the claims process if you were injured by a driver not covered under the policy.

Coverage Excludes Damage

Your claim will be carefully reviewed by the insurance company, who will look to determine what caused your injuries. Every policy has a list of what won’t be covered. If your injuries fall under a policy exclusion, your claim will be denied. Policy exclusion examples include storm damage and intentional vandalism.

Cause of Injury Is Disputed

It’s vital to give insurance companies substantial proof of the cause of your injuries. Your claim will be denied if you gather evidence insufficiently and your claim lacks support.

A denial can be justified by claims that injuries already existed when the accident happened, or that your injuries were made worse by your own conduct. You need to always give clear evidence linking your accident to your injuries.

Injury Extent Is Disputed

Claims can be denied when insurers believe your injuries’ extent has been exaggerated. As an example, if you’ve been in a minor accident, the insurer may find it hard to believe that you ended up with a spinal cord injury. It will be the opinion of the insurer that this kind of injury doesn’t usually happen in low-impact crashes.

It’s vital to give detailed information such as medical evaluations and reports in order to support your claim. It’s essential to provide direct, clear evidence establishing that your injuries are as bad as you’re claiming and were the result of your accident.

Not Enough Evidence To Establish Fault

Insurance claims like injury claims and property damage claims often get denied when a dispute exists regarding liability or fault. Your claim will only be approved if clear evidence shows your injuries are the fault of the insurer’s policyholder. Your claim will get denied if any indication exists that their policyholder isn’t at fault.

Claims like an injury claim or property claim can also get denied when evidence shows the policyholder isn’t 100 percent at fault for an accident. Anybody contributing to an accident can be held liable for injuries in California. Your accident will be carefully investigated by insurers so they can figure out if you or someone else contributed to it. If the evidence shows multiple parties are to blame, insurers will likely deny your claim.

Claim Not Filed in a Timely Manner

It’s vital to quickly act and contact the insurance company as quickly as possible after an accident. Most insurers place strict limits on how much time you’re given to file a claim. You’ll typically need to submit a claim in a “reasonable” time frame following an accident.

Some insurers give a specific definition of what a reasonable time frame is. Others won’t. Your claim could get denied if the insurer feels your claim wasn’t filed on time. This can sometimes be a bad faith tactic which is designed to prevent the insurer from having to pay you a fair settlement.

Claim Denied Without Adequate Investigation

Insurers need to exercise due diligence when handling claims. This should include investigating the claim and the relevant circumstances. Sometimes, however, insurance companies act in bad faith and deny claims without investigating them. Always ensure you’re given a legitimate reason that your claim was denied. If your claim gets denied without a reason or justification, this is a red flag.

You Don’t Have a Lawyer

If you don’t have a lawyer, insurance companies won’t hesitate to deny your claim. They’ll assume you don’t know what your legal rights are and they’ll try to take advantage of this. They might delay your claim’s processing unnecessarily, or make it hard for you to talk to a representative.

Strategies like this are intended to get you to buckle to pressure and accept the insurance company’s low ball offers. You’ll only ever see low ball offers from insurance companies if you don’t have a lawyer since insurers know you can’t sue over a low ball offer and win without a lawyer. You can protect your legal rights and ensure your claim receives the attention it deserved by hiring legal representation.

Understanding Your Policy’s Fine Print

The goal of any insurance company is to make money by limiting payouts. It’s vital to carefully read your policy so you understand what gets covered. Insurers are notorious for legal loopholes which can be used to deny you coverage after an accident.

Misunderstandings of coverage can lead to denials. For example, imagine you’re cohabiting with your fiancee and you want to combine your car insurance. You get in an accident that’s someone else’s fault, and that someone else is underinsured. So, you file a claim with your underinsured motorist coverage that you purchased together with your fiancee.

You live together with your fiancee and have a child together, but you’re not married legally. You dropped your own insurance policy to save money and got added to your fiancee’s policy. However, to your surprise, your claim gets denied since you’re not a legal relative or spouse.

This denial might be allowed to stand in court even if the language allowing the denial is obscure, fine print language. For example, the policy’s language may give you coverage when you cause an accident, but may deny coverage to those who aren’t legal relatives or spouses when injuries are caused by other underinsured motorists.

This is just one example of how fine print can come back to bite you after an accident. All insurance companies use fine print like this to get away with not paying injury victims. For this reason, it’s vital to always read and understand the fine print of your policy.

Immediate Steps to Take After Receiving a Claim Denial

Steps you should take after having your claim denied include:

Carefully Read the Denial Letter

The first thing to do after having a claim denied is to carefully read the denial letter. Denial letters will typically include evidence to support the decision. You can’t know what the best step to take next is without carefully reading the denial letter. What you do next will depend upon the reason for the denial. For example, there might not be a lot you can do if it was denied due to lapsed coverage. However, if it appears it may have been denied in bad faith, then you may be able to recover compensation with the help of a lawyer.

Note Important Appeal Deadlines

The appeals process often involves important deadlines which must be met for an appeal to be successful. You need to note these deadlines if you wish to be able to successfully appeal the decision.

Gather Relevant Documentation

You’re going to need to collect evidence to support your denial appeal. You will want to:

• Obtain a police report copy: When car accidents occur, the police sometimes take down detailed accounts of accidents which describe the scene, document injuries and include testimony from bystanders. The police report may include an initial determination of fault, and you can use this as evidence in an appeal.
• Obtain medical records: Obtain medical records as well as proof of any medical expenses. Receiving medical attention immediately after your accident can benefit your claim greatly later on. Gather all medical documents which describe any injuries or procedures you go through. Include documentation of physical therapy needed as well.
• Obtain video and photo evidence: Get videos and photos of the accident and accident scene, including images taken with a phone or any surveillance footage available from buildings nearby. Photos and videos can provide powerful evidence.
• Obtain witness testimony: Get any witnesses’ contact information. Witnesses may have objective views of accidents and may provide strong evidence that someone else was at fault for your accident.

Hiring a lawyer can assist you in gathering evidence and putting together a successful appeal.

How To Appeal an Insurance Claim

The first steps towards appealing an insurance claim are thoroughly reviewing the denial letter, gathering evidence and contacting the insurance company to let them know you intend to dispute the denial.

Once you have done these things, the next step is to formally file an appeal. This typically involves writing a letter which details why you think their denial was wrong. This letter should provide evidence which backs your claims up.

If your appeal gets denied, you can then request than an independent third party reviews the denial. This will involve a neutral party evaluating the decision made by the insurance company. The insurer will need to abide by their decision.

At any point in the appeals process, you may also wish to consult with a lawyer. Consider hiring experienced personal injury lawyers, as they typically have plenty of experience in insurance disputes. They can give you advice on what the best step for you to take next is, including potential litigation.

Crafting a Compelling Appeal Letter

To craft a compelling appeal letter, you will first need to gather relevant information. This will include the claim form, any documentation supporting your claim, and the insurance company’s rejection letter. Review why your claim was denied and identify any missing information or errors.

Once the necessary information has been gathered, organize it in an easy-to-understand, logical manner. This way, the insurance company can more easily understand your case and review your appeal. Organize things like follows:

Error 1

• Insurer’s error
• How you to propose to amend this error
• Any documentation or evidence that supports you

Error 2

• Insurer’s error
• How you propose to amend this error
• Any documentation or evidence that supports you

Error 3

• Etc.

Write your appeal in a professional, polite manner. Start your letter by addressing your insurer and adjuster. State the reason you’re writing the letter and provide an overview of your case which is brief.

Maintain a respectful, calm tone. You might be frustrated with your denial. However, letting this frustration show in your letter won’t help you win your appeal. Consider asking a family member or friend to review your letter before sending it. Ask them to make sure you are polite enough in your tone.

Include supporting documentation, meaning all of the evidence you’ve gathered that supports your claim. Reference this documentation in your letter and explain how it supports your claim. Keep copies of this documentation for your records.

If your claim got denied due to an omission or error on your part, make sure you explain this in your letter and own it. Denying that you’re responsible for an error won’t help you win an appeal. Provide any additional explanation or information which can help to clarify your situation.

Make a formal request that the insurer review your claim and explain their decision. Indicate you’re willing to provide any documentation or information they request.

Conclude your letter by thanking the insurer for their consideration and time. Provide contact information, including your email address and telephone number.

Follow up with the insurer after sending the appeal letter.

When To Seek Legal Representation

There are scenarios when it is wise to hire a personal injury lawyer.

Complex cases are one scenario when it’s wise to hire a personal injury lawyer. A lawyer can not only make sure you don’t make any mistakes in complex cases, but it will simply be great to have a lawyer handle the complex, time-consuming claims process for you while you simply focus on recovering from your injuries.

It’s important to hire a lawyer if any disputes over liability occur. Experienced lawyers will know exactly how to prove that another party was at fault for your injuries.

If the process is simply becoming overwhelming for you, consider hiring a lawyer. They can handle every step of the legal process for you while you recover from your injuries.

Finally, if the injuries you sustained are serious, it’s best to hire a lawyer. Serious injuries mean a lot of money is on the line, and you simply won’t be able to convince an insurance company to pay you anywhere near what you deserve without a lawyer. Insurance companies know they’re obligated to pay you for your injuries up to policy limits if their insured is at fault. They also know they don’t have to live up to this obligation if you can’t enforce this obligation by suing them and winning. You’ll need a lawyer to sue an insurance company and win.

How a Personal Injury Lawyer Can Strengthen Your Case

There are many ways a lawyer can assist you.

A lawyer can provide specific expertise with insurance law and regulations. Your hope of taking on an insurance company in court and winning without this knowledge of law and regulations is slim to none.

A lawyer can provide their negotiation skills to you. They can negotiate with the insurance company to make sure you are paid every penny you deserve.

A lawyer has access to resources such as accident reconstruction experts which can make or break your case.

A lawyer may also have experience with the specific type of personal injury lawsuit you need to file. For example, if you’ve developed a disease due to exposure to a dangerous chemical like paraquat & Roundup, you’ll want a lawyer with experience handling toxic exposure cases.

Suing an Insurance Company for Denying a Claim

If your insurance appeal gets denied, then your next option may be to sue the insurance company. You will definitely want to take this step if you feel your claim and appeal have been wrongly denied.

It is important to have experienced legal representation if you want to take on an insurance company in a court of law.

The good news, however, is that once you hire experienced legal representation and file a lawsuit, there’s a good chance your case won’t actually make its way to trial. A lot of the time, insurance companies will simply do whatever they can to deny you payment up until the point you hire a lawyer. They’re often just testing you to see if you’ll hire a lawyer, since they know they don’t have to pay you what you deserve if you can’t sue them and win.

Once you hire a lawyer, the insurance company will often decide it’s a better idea, financially, for them to just pay you what you deserve rather than to go to court, lose, and have to pay you what you deserve anyways on top of expensive legal fees.

Hiring a lawyer after being injured in an accident is the best way to ensure you receive the most compensation possible for your injuries.