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Filing a personal injury claim can often be a long, stressful, and drawn-out process, making it incredibly disappointing if the insurance company ultimately denies your claim. However, an initial denial does not necessarily mean the end of the road.
Below, we’ve provided information about potential reasons for denial, your rights as a claimant, and how to appeal or pursue legal action to ensure you receive the compensation you deserve.
Common Reasons for Denial of a Personal Injury Claim
One of the primary aims of an insurance company is to minimize the amount of money they need to pay out on behalf of the person responsible for your damages, their client. To accomplish this objective, insurance adjusters investigate your personal injury claim, looking for discrepancies, fraud, or anything else that might reduce or negate the amount of compensation you are entitled to.
Some of the most common reasons insurance companies give for denying a personal injury claim fall under the following categories:
Insufficient or Inadequate Evidence
Different types of evidence can support various personal injury claims, such as medical malpractice, slip and fall, dog bite, vehicle accident, and worker’s compensation. Some of the most common forms of evidence include medical records, police reports, repair estimates or bills, eyewitness statements, photographs, and diagnoses from health professionals.
Insurance companies often claim that you haven’t provided sufficient evidence to prove the extent of your injuries or damages or that pieces of evidence are missing or incomplete.
Incomplete Information
If you fail to provide all of the information and documentation requested by the insurance company or do not completely and correctly fill out the appropriate claim forms, an insurance company may claim they lack the information they need to process your personal injury claim.
Insurance Policy-Related Issues
Some insurance policies have exclusion clauses stating specific incidents will not be covered. For example, if “acts of God” are excluded, the insurer might argue that a blizzard caused your car accident rather than the other driver. Similarly, specific injuries might not be covered, especially if you have a pre-existing medical condition that could have contributed to your injury.
In addition to policy exclusions, most insurance policies have coverage limits that may affect your personal injury claim. If your damages exceed the amount the policy allows, the insurer might deny your claim outright or offer a lesser amount than you seek.
Many insurance policies also include specific deadlines by which you must notify them of the accident or injury. Failure to inform them within the appropriate time frame might lead to a denial of your personal injury claim.
Fault Dispute
One of the insurance adjuster’s jobs is to determine the percentage of fault for each person involved in an accident or incident. Depending on the state in which the incident occurred, your degree of fault might significantly affect how much compensation you receive.
Suspicion of Fraud
Any suspected fraudulent activity will likely result in a denial of your personal injury claim. Fraudulent activity can include discrepancies, inaccuracies, misrepresentation or exaggeration of facts, injuries, and damages.
What Rights Do Claimants Have?
When an insurance company denies your personal injury claim, it’s important to understand your rights.
- You have the right to a clear explanation of why your claim was denied. Usually, the insurer will include this information in a letter.
- You have the right to review the insurance policy, which is especially useful if your claim was denied based on coverage limits, exclusions, or other policy-related issues.
- All claimants also have the right to fair treatment. Insurance companies are legally bound to act in good faith and handle claims fairly.
- If you disagree with the insurance company’s reasons for denial, you have the right to appeal their decision. The insurance company will have a formal process for you to follow. It would be prudent at this point to exercise your right to seek legal representation.
A personal injury lawyer will have the necessary expertise to help you navigate the appeals process or pursue legal action if you cannot reach a fair settlement.
How To Appeal a Denial of a Personal Injury Claim
Once you have reviewed the denial letter and insurance policy to better understand the reasons given for the denial of your claim, you can decide on the steps you need to take to address them. For example, you’ll need to gather additional evidence or documentation to support your claim if information is missing, inaccurate, or incomplete.
Submit a formal letter of appeal, or have your lawyer draft a demand letter that specifically addresses each of the reasons given in the denial letter. Include whatever additional evidence or information you have gathered. Make sure to follow the procedures and timelines the insurance company gives you for the appeals process.
Organize all your information and keep detailed records of any communication (letters, texts, emails, phone conversations, meetings) you have with the insurance company.
Pursuing Legal Action When Your Claim Is Denied
If the insurance company denies your appeal, you should consult with an experienced personal injury lawyer. They will review your case with you and guide you on your options. A personal injury lawyer can:
- Negotiate with the insurance company on your behalf
- Provide mediation services, which can help resolve disputes out of court in some cases
- File a lawsuit, if necessary, including handling all paperwork
- Represent you in court
Don’t be afraid to be persistent. Some insurance companies may deny an initial claim or appeal, hoping the claimant will not pursue the matter further. If you decide to pursue legal action, finding a law firm like Warren Allen LLP specializing in personal injury law is an important first step.
You don’t have to do this alone. Hiring a personal injury lawyer to help with your personal injury claim can provide the resources you need to get the financial compensation you deserve.
