When you have an insurance claim, you expect it to be processed quickly and fairly. Then, you hear from the insurance company. They have denied your claim. You’re angry, frustrated, and wondering what to do.
If your insurance claim is wrongfully denied, there are things that you can do. It’s important to understand why the claim is denied and how to determine your next steps. Our lawyers explain what to do when your insurance claim is wrongfully denied.
At Haun Mena, we are experienced insurance claim lawyers who help people respond when their insurance claims are denied. The sooner you involve us in the process, the sooner you will have an experienced team on your side who knows exactly what to do. Contact us today to talk about your situation and start your case.
What To Do If Your Insurance Claim Is Wrongfully Denied
Note: Some processes vary slightly depending on what type of claim you are appealing – auto, homeowner, health insurance, or another type. However, the general principles are similar.
If your insurance claim is wrongfully denied, don’t panic – there are things you can do.
Insurance companies deny a percentage of the claims filed on their policies, and most people give up. However, you can challenge the decision.
1. Find out why the claim was denied
Start by getting the insurance company to explain why the claim was denied. The insurance company must tell you in writing. They cannot just leave it to you to guess why they didn’t pay the claim. If you don’t already have a written statement from the insurance company explaining why the claim was denied, ask them for it.
2. Evaluate the reason the claim was denied
Once you know why the insurance company is giving for the denial, review it. There are many reasons that insurers deny claims. How you proceed depends on the reason that they provide.
Here are some reasons that insurance companies have for denying claims:
- The insurance company is missing information needed to process the claim
- Damage needs to be documented further
- Insurance company representatives are hoping that you will give up
- Claims adjusters are under pressure to lower their payout amounts
- They’re accusing you of missing a filing deadline
- The type of loss is not covered by the policy
- Amounts requested exceed policy limits
- Premiums were not paid
- The injured party isn’t covered by that insurance policy
- Inadequate maintenance and lack of care (homeowner policies)
- Medical necessity (health insurance)
- Determination of fault (auto insurance)
Once you have the reason that the insurance company denied the complaint, you can challenge it.
3. Remedy the situation, if possible
Sometimes, you can provide more information and ask the insurance company to reconsider. For example, if the insurance company doesn’t have sufficient information about the amount of damages, you may be able to provide additional information.
Carefully read the reasons that the insurance company gave for denying the claim. If it’s possible that you can clarify their questions or provide more detail, you may be able to reach a different result without formally appealing.
4. Tell the insurance company you want to appeal
The insurance company will have an internal appeal process. Be sure to submit the appeal in writing or electronically, as opposed to over the phone. The insurance company will give instructions on how to file the appeal and what information to provide. Be sure to follow these instructions carefully.
They will need the policy information and the specifics of the claim. There may be multiple rounds of appeals available within the company. It may seem pointless to file an internal appeal, but it gets another set of eyes within the company looking at the case. It is possible to receive a different decision from the insurance company.
5. Consider using an appraiser
For auto insurance, you may be able to use an appraisal process to resolve a dispute about value. The appraisal process aims to resolve disputes using a third appraiser that acts as an umpire.
6. Request an external review
If the insurance denial is for a medical procedure, you can ask for an external review. An independent review puts the case before a neutral third party. An external review is available if the denial is based on experimental, investigative, or medically unnecessary treatment. It is not available for denials based on policy coverage.
The review may be expedited if the matter is urgent. You may be able to skip the internal review and head straight to an expedited review for an urgent healthcare matter. To ask for an external review, you complete a form. It should have been provided to you by the insurance company when they sent you the final denial.
7. File a complaint
The Texas Department of Insurance regulates and oversees insurance activities in the state. They receive complaints from insurance companies.
It’s important to understand that they do not have the ability to intervene in all cases. However, filing a complaint can still be helpful in some circumstances. They accept complaints online. They also operate a phone helpline to answer insurance questions.
8. Take legal action
Even after appeals and complaints, you may find that the insurance company still isn’t fairly paying a claim. Fortunately, there is still something that you can do. You can bring a legal claim to enforce your rights and get the coverage you deserve.
Suing an insurance company can be complex. For example, for car accidents, Texas law is specific. You first bring the claim against the person or party legally responsible for the crash rather than against the insurance company. You may sue the insurer once liability has been determined. This may seem like a technicality, but it’s important.
A pre-suit notice letter may be required for first-party claims to claim attorney’s fees. In addition, time deadlines apply to filing claims, including a four-year statute of limitations for breach of insurance contracts and a two-year limit for breach of the duty of good faith and fair dealing.
If the insurance company refuses to fairly pay your claim, you can take legal action. It can be a viable way to get the payment you deserve after the insurance company denies your claim.
Our Attorneys Can Help If Your Insurance Claim Has Been Wrongfully Denied
The Haun Mena law firm is a group of trained and experienced legal professionals. We specialize in helping people respond when the insurance company denies their claim. Our team can represent you throughout the entire process. We know the ways to pursue the appeal and any legal action efficiently, with the goal of getting you the fair payment that you deserve quickly.
Contact us today to talk about your case and begin.