Receiving a claim denial can be baffling, especially when you have done everything right. However, it is unfortunately possible to accurately document the facts, your injuries, and the course of your treatment and still find the other driver’s insurance refuses to offer a settlement.
There are several reasons this can happen and many times, it is not your fault. But that is small comfort if you require compensation for medical bills, lost wages, and pain and suffering. Here are the reasons claims are denied and what you can do if you face this situation.
Reasons for Claim Denial
Generally, claims are denied because the adjuster believes your claim clacks merit. They may determine the fault of the accident is with you or your injuries are significant. Many adjusters come right out and accuse you of exaggerating your symptoms.
Adjusters may believe their insured’s versions of events or point out that you never complained of pain at the accident scene. Sometimes, the denial results from the testimony of an eyewitness you never knew existed. If there is no police report filed on the accident, these claims are hard to counter.
Other reasons concern coverage. If the accident occurred due to a hail storm, high winds or other bad weather, that can be considered an “act of God” which is not covered under most car insurance policies. This excuses the other driver from any negligence claim based on the accident occurring due to weather rather than human error.
You may also face a denial if the other driver allowed their insurance coverage to lapse. If the other driver did not maintain their insurance policy, the company has no obligation to cover your claim. Your only other option is to pursue your own policy for uninsured motorist coverage.
Your claim may also be denied if you did not notify the insurer on time. That is why personal injury attorneys and your own insurance company encourage you to report accidents immediately.
Many insurance companies allow an opportunity to appeal. This in-house review assigns another adjuster to take a new look at your case and make a new determination.
When you receive notice of the claim denial, it should also include instructions for accessing the appeal process. It normally involves sending notice to the insurance company usually in the form of a letter. This transfers your file to the relevant department to start the appeal.
From there, you or your attorney outline where the original adjuster made a mistake and explain why your claim should be approved. This is often done in the form of a demand package that includes accident reports, witness statements, medical records, and any other documentation that supports your claim.
If successful, you can start negotiating to settle the matter. Since this step is often more thorough, there is a good chance you can conclude your claim during the appeal.
As you go through the claims handling process, insurance adjusters may use delay tactics. They may question you on aspects of the claim repeatedly as a way to get you to make conflicting statements. Repeated record requests are also part of this interrogation. It is why many insurance claim files have multiple copies of the same chart notes.
Larger companies have policies where certain types of claims are initially denied. They may include injuries limited to soft tissue or neck injuries or they may not investigate fault at all if it is disputed. This first review denial is a delay tactic that is meant to discourage claimants. The intention is to prevent the claim from moving forward.
Lack of communication is also a delay tactic. If you are handling a case without an attorney, adjusters know you do not have the time to continually follow up. Therefore, they often cut off communication as another way to encourage you to give up.
These tactics can fall under a legal theory called bad faith. Basically, all insurers have a duty to act in good faith when they receive a claim. That means they agree to review the facts, see the medical records, and fairly assess each claim based on its original elements.
Bad faith comes into the picture when an insurance adjuster fails to investigate the claim. They may deny it without looking at the documents or ignore accident or police reports in favor of the insured’s version of events. These cases can result in substantial damages to plaintiffs if they can be proven. Unfortunately, that is often difficult to establish.
Call an Attorney
The best way to assure an insurance company takes your claim seriously is to hire an attorney. Many of these tactics are reserved for those who do not have attorneys and when you try to handle a claim on your own, you will likely face every single one of these obstacles.
The Law Offices of Alan Levar offers dedicated legal representation to accident victims in Little Rock. If you are facing a claim denial and do not know the next steps, contact our office today to schedule your free consultation.