There are a number of reasons why an Insurance Company may not proceed with a claim, some examples are as follows:
- Failing to pay a claim in a timely manner;
- Offering an amount below what the claimant is entitled to;
- Failing to defend a policyholder against a third-party claim;
- Using a policyholder’s previous claims as grounds to deny a new claim;
- Failing to conduct a reasonable and full investigation of the claim;
- Misrepresenting important facts or insurance policy provisions as they relate to coverage;
- Misuse of claimants’ medical records;
- Requiring excessive paperwork;
- Cancelling a policy after a claim is made;
- Purposely targeting high-cost claims for denials; and
- Ignoring expert opinion in cases where that opinion would result in a claim being paid out (such as finding that a death was suicide when a medical examiner has ruled it accidental);
There are a few a few things to consider when an insurance claim is denied:-
- Don’t assume that the first “no” you receive is final.
About 10 percent of all insurance claims are unjustly denied but less than 1 percent of people making insurance claims even question their insurer when their claim is denied. The majority of policyholders who do contest their cases either win their cases or improve their settlements.
- Insist on a written explanation. An Insurance Company is required to provide written explanations of claim denials. Failure to comply may constitute an illegal practice by the insurer.
- Read your policy carefully to determine if the claim was legitimately denied.
The insurance company may have interpreted a clause in your policy differently from the way you understand it. Respect your sense of fairness and what you expect the policy to cover. If the ruling doesn’t sound fair, there’s a good chance that it isn’t.
- Do not accept filing errors as ground for refusal.
Always follow your insurer’s instruction for filing a claim. But if you fail to fill out a form correctly, or if you miss a deadline for submitting a claim – even if you are months late – an insurance company cannot refuse to pay an otherwise valid claim unless the company can show it has been harmed by your error or prevented from making an adequate investigation due to your delay.
- Ask your insurance agent or group policy administrator at work for support.
The agent from whom you purchased your insurance has a duty to make sure the coverage protects your interests.
- Contact the insurance company directly.
If your insurance agent or claims administrator doesn’t resolve the problem within 30 days, telephone the insurance company yourself. Be polite but persistent, and keep going up the corporate ladder. Be sure to make a record of all phone calls, including the names and positions of everyone with whom you speak. Save your phone bills that list the calls. Follow up each call with a brief letter stating your understanding of the conservations, and requesting a response within 30 days.
- Complain in writing if your phone calls don’t work.
Begin with the person who denied your claim, then write to the person’s supervisor. Include your policy number, copies of all relevant forms, bills, and supporting documents and a clear, concise description of the problem. Request that the insurer responds in writing within three weeks. Keep copies of all correspondence. Send letters by registered mail. Explain what negative effects the denial of your claim is having. Use a courteous, unemotional tone and avoid rude or blaming statements.
- Write a follow-up letter.
If you receive no response, send follow-up letters, with your original letter attached to the insurance company’s consumer complaints or customer service department and to the company president. In most states, failure to respond promptly to letters regarding claims is an unfair insurance practice.
- Look for violations.
If your claim is denied because of a reduction in coverage, determine if you were ever notified about that reduction in coverage. If you were not, then you have a good chance of winning your claim since failure to notify the patient of a reduction in coverage is a violation of the law.
If you have been denied a legitimate insurance claim please contact our office for helpful and impartial advice. There is no obligation on you to proceed once you have spoken with one of our Solicitors and all communication will naturally be completely confidential.
Our Freephone No: 1800 515 515 if you wish to call or complete the enquiry form on this page.