INSURANCE CLAIM DENIAL LAWYER/INSURANCE CLAIMS DENIALS ATTORNEYS FREQUENTLY ASKED QUESTIONS

An insurance claims denial does not mean a policyholder’s claim is not valid. An insurance company may have wrongly denied a claim, or rejected it because it contained missing, or incorrect information. When an insurance company denies a policyholder’s claim, they can contact an insurance claim denial attorney in their state by selecting the state and county where the  policy coverages apply, at insurance-claims.usattorneys.com, or by calling 866-335-8999 to get in touch with an insurance claims denial lawyer nearby. Insurance claims attorneys can be helpful with policy reviews, and enforcement interactions with companies who do not uphold the terms of insurance policy documents when claims become problematic after unjustified denials occur.

DETERMINING WHY an INSURANCE COMPANY DENIED a policyholder’s INSURANCE CLAIM

Policyholders should be aware of the types of insurance coverages available, and what to look for when purchasing viable coverage options for their individual needs.  It is most important to understand the inclusionary coverages laid out in the policy and items that are not covered, in the event a policyholder needs to make claim.  Claims are often denied because a policyholder is unaware of the guidance in the insurance policy document that strictly prohibits coverage of certain losses.  Before attempting to file a claim with an insurance company, individuals should assess the damages they are trying to resolve and read over every clause in their existing policies to determine that they have a valid claim to submit to their carrier.  An insurance claims attorney can help with a policy review and questions individuals have when insurance carriers do not completely address policyholder concerns.

REASONS WHY THE INSURANCE COMPANY MAY DENY an INSURANCE CLAIM

Damage recovery under most insurance policies is limited to losses due directly to the occurrence of an insured peril named within the insurance policy itself. Losses caused by some intervening source that are not insured by the policy are not covered. Insurance disputes arise in many ways. An insurer may not offer fair value for property damage under a policy, or an insurer will deny a claim, supporting the denial with transference of fault onto the policyholder, stating that they intentionally caused the loss, or misrepresented themselves in order to purchase the policy at issue. Other claims are denied when insurers blame late insurance premium payments for gaps in coverages. There are times when only partial benefits are approved for payment, and this is a partial denial of benefits. When individual’s claims are denied due to dishonest dealings as a matter of company policy, policyholders should contact legal counsel to assist in the settlement of the matter.  Denial of legitimate claims on a paid-up policy could be an incident of consumer fraud, which is actionable in court. Common reasons for claim denials include:

1. Company does not want to pay, bad faith contract.
2. Mistakes on an application.
3. Lack of coverage: The claim does not cover the damages a policyholder is seeking.
4. The claim was not filed correctly.
5. Policy modifications were made after a claim was filed.
6. Misrepresentations of a policyholder’s true damages.
7. There was a gap in coverage due to non-payment, or late payment of premiums coinciding with a loss event.

Click to Call 866-335-8999 to Get Connected To an Insurance Claims Denial Attorney

EXCLUSIONS IN an INSURANCE POLICY THAT COULD AFFECT a policyholder’s INSURANCE CLAIM

Exclusionary clauses are part of insurance policies, outlining the exceptions to coverages that the insurer and the insured agree upon prior to signing a policy.  Certain exclusions for claims regarding flooding, wind, or storm damage, and earthquakes may be common, depending on the state where a policy is issued.  A policyholder can buy add-on policy coverage riders in some states to cover those types of events.   An insurance denial attorney can review a policy and make certain that the denial was based on a legitimate exclusionary clause within the signed document.

THE INSURANCE COMPANY MAY BLAME the policyholder FOR THE DAMAGE

Investigations by an insurance company to determine the cause of insured property damage may shift fault in a policyholder’s action, claiming that the policyholder caused, or exacerbated the loss outlined in a claim due to a lack of routine maintenance and upkeep, or caused damage in some other way.  When this happens, it may be necessary to have an outside objective insurance adjuster review the damage.

THE INSURANCE COMPANY MAY QUESTION an INJURY IN the INSURANCE CLAIM

Proof of injury for an insurance claim submission often requires supporting medical documentation, photographs of bodily injury damage, and records of healthcare appointments related to the personal injury after an accident, or mishap leading to harm. A healthcare provider can provide x-rays, and other diagnostic reports when necessary to support a claim of injury. It is helpful for accident victims to seek medical attention soon after being injured to make certain that injuries which are not visible to the naked eye are caught before they can cause more severe harm.

INSUFFICIENT EVIDENCE OF a policyholder’s INSURANCE CLAIM

Proof is always necessary regarding the particulars of an insurance claim denial, whether it is through photographic proof of physical damage to property, or via reports from experts who have reviewed damage and given estimates for repairs.  Insufficient evidence denials can be overturned by providing the insurer with any necessary information to support the submitted claim of a policyholder.  An insurance claims denial attorney can be helpful in the determination of the support documents an insured may need to reverse a claim.

MISREPRESENTATION ON an INSURANCE CLAIMS APPLICATION

There are times when individuals misrepresent the facts in order to gain access to insurance coverage.  If that is not the case, and an insurance company denies a claim based on a question of misrepresented facts by a policyholder when they filled out an insurance application, a claims denial attorney can be of assistance in clearing the matter by addressing areas under dispute.  There are cases when an insurance agent filled out an application for a policyholder and filled out an answer to a question incorrectly.  If the insurance company cannot prove that a policyholder purposely misrepresented themselves, then the claim denial should be reversed.  An experienced  attorney can help with a defense to the misrepresentation.

INSURANCE CLAIM DENIAL DUE TO FAILURE TO PAY INSURANCE PREMIUM

Late payments, or the lack of payments may cause gaps in coverage of an existing policy.  If an unfortunate event occurs during that period of time when the payment for a policy has not been recorded, the insurance company may have a valid legal standing not to pay an insurance claim. However if a policyholder can prove through bank statements, or other proof of payment avenues that a premium was paid on a certain date, a claim denial may have to be reversed.  A claims denial attorney can be helpful with this problem by corresponding with the insurance company and providing them supporting documentation that amounts due on the policy were paid at the time of the damage reported in the claim request.

FAILURE TO FOLLOW INSURANCE POLICY REQUIREMENTS

When  a person buys an insurance policy, they must read each clause carefully and make sure they agree with all of the applicable terms for coverage of  items being insured, and clarify the coverage amounts for each type of damage loss scenario.  A claims denial attorney can go over a policy with a policyholder to make certain they were acting within policy requirements regarding the period of time allowed to make a claim after damage was sustained, and in health insurance cases, following pre-authorization requirements, or services provided within certain networks for example.

HOW TO CHALLENGE an INSURANCE CLAIMS DENIAL

The best way to challenge an insurance claims denial is to keep the lines of communication open with the insurance carrier and make certain that simple mistakes, or misunderstandings are cleared up.  Formally, it is best to communicate in writing so a policyholder has a paper trail of events and actions between the policyholder and the insurance company regarding the denial.  There is a process to appeal an insurance claims denial and make reports to the state overseer of insurance products.  An insurance claims denial attorney can draft a formal appeal letter to get the action started.  If there is no resolution after an appeal letter is sent, litigation may have to be started.  Keep in mind that there are certain regulatory statutes of limitations for how long a policyholder has to initiate legal action after a claim denial. When an insurance company denies a claim because they are acting in bad faith, a policyholder may be able to recover the amount of the original claim, financial losses connected to the bad faith denial such as attorney fees and court filing fees, monetary compensation for emotional distress and punitive damages in some cases when it can be proven that the insurance company was acting in a malicious willful manner against the rights of a policyholder.

Find an Insurance Claim Denial Lawyer Near Me

THE DIFFERENCE BETWEEN DENIED INSURANCE CLAIMS VS. REJECTED INSURANCE CLAIMS

Denied claims often have a corresponding reason to a clause in the policyholder’s legal contract and can be appealed when, and if there is a supporting legitimate reason to uphold the claim costs.  Rejected insurance claims have not been completely processed, because they are filed with an error that requires a policyholder to fix before they can be processed by the insurance company for payment under the policy guidelines.

HOW TO WRITE AN INSURANCE CLAIM DENIAL APPEAL LETTER

Policyholders should make certain claim denials have nothing to do with policy non-covered outlined services, exceeding coverage limits and, in the case of health insurance, a policyholder seeking services out-of-network.  An appeals letter should reference the date and claim denial reference number and reason for denial, followed by the policyholder’s account of actions leading to the initial claim filed. Policyholders should outline the reasons the denial should be reversed, providing supporting documentation and reports when available.  The original letter should be mailed to the claims dispute department of the insurance carrier and a copy of the letter should be sent to the state insurance overseeing agency and mailed with proof of delivery in case an insurance carrier claims they never received an appeal letter and there are time constraints imposed by the statutes of limitations to move forward with legal action for insurance disputes.

DIFFERENT TYPES OF INSURANCE CLAIMS DENIAL

Insurance companies are always happy to receive premium payments, but sometimes they are not quite as eager to pay claims. When individuals purchase insurance and claims are denied, policyholders may need an insurance lawyer to fight for the benefits that were purchased.

• Homeowners Insurance Claims Denial – Recovery under homeowner’s policies is limited to losses due directly to the occurrence of an insured peril. Losses caused by some intervening source that are not insured by the policy are not covered. An insurer may not offer fair value for property damage under a homeowner’s policy, or an insurer will deny a claim, supporting it by placing fault on the policyholder, stating that they intentionally caused the damage.
• Car Insurance Claims Denial – Motor vehicle insurance is a contract between an insured and an insurer, where the insurer assumes the risk of any loss the owner, or operator of a motor vehicle may incur through damage to property, or persons as the result of an accident. It is important to reference a car insurance policy and utilize the services of a claims denial attorney to review the document before making an appeal to have a claim reversed.
• Business Insurance Claims Denial – Insurance for business is similar in many ways to the one for individual property. Business interruption is a standard component of a business property insurance policy. This type of coverage is designed to protect businesses against lost profits due to interruptions to their operations and policyholders must support their claims as outlined in the insurance document.
• Health Insurance Claims Denial – Health insurance policies are a tricky business when individual policyholders find it difficult to understand the policy language concerning basic coverages, deductibles, pre-authorization approvals and in and out-of-network provider differentiations for hospitals and healthcare providers utilized. Common reasons for health insurance denials include:

1. Exceeding policy coverage limits of the medical insurance plan chosen.
2. Incomplete, or missing information in the submitted claim documents, either from the patient, or medical billing coding errors caused by a provider.
3. The health insurance plan may not cover the claim, considering it non-medically necessary.
4. A specific drug or therapy is off-formulary and not part of the insured’s health plan.
5. Policyholders may have used out-of-network services, or used health insurance when traveling out of state when a plan requires “in-network providers only.

DENIED INSURANCE CLAIMS.

If a denied claim cannot be settled between the parties of the contract, then legal action will be based on state and federal insurance laws. Insurance policies are a contract between the insured party and the provider, so when a dispute arises about questions of coverage, or denial of legitimate claims comes up, the state contract laws will be the basis of argument for a policyholder’s case. If an individual has questions regarding the basics of insurance policy clauses, an experienced insurance attorney may be of assistance and respond on an individual’s behalf when denied claims occur.

If your insurance company denied your insurance claim contact an insurance claim denial lawyer using the USAttorneys.com Insurance Claim Denial Law Firm locator. Select your state then your county to be directed to a claim denial lawyer near me or call 866-335-8999.