Millions of accidents occur yearly in the country, with nearly two million being injury crashes. While multiple parties shoulder the costs of the injuries, private insurers are responsible for 50% of the claims. And as much as an injured person has a right to receive compensation from the at-fault party’s insurer, a significant number of the claims get denied.
However, the rejection of an insurance claim, though distressing, is not always final. One can appeal the decision by writing to the company, providing evidence to prove the claim’s validity.
The Appeal Process
If an insurance provider rejects a claim, they send a denial letter explaining their decision. However, if unsatisfied with the verdict, a claimant has a right to appeal it by following the specific insurer’s claim resubmission guidelines.
Step 1: Review the Denial Letter
The first step is to understand why the claim was denied. The denial letter sent by the insurer usually indicates the reasons, which may include:
- Disputed liability – One of the most common reasons for claim denial is a dispute over liability. The insurance might argue the claimant was responsible for the accident based on available evidence. For instance, if they’re 50% or more responsible for the accident, they cannot receive compensation based on the comparative negligence rule. In most cases, this may happen where the evidence submitted is inadequate to demonstrate the at-fault person’s negligence.
- Incomplete medical records – For a claim to be compensated, it must satisfy the four principles of negligence–duty of care, breach of duty, causation, and damages. Despite proving the first three, there must be adequate supporting documents to prove damages, such as doctor’s reports, prescriptions, X-rays, hospitalization bills, rehabilitation costs, etc.
- Delaying seeking treatment – If one fails to seek treatment immediately after the accident but does so later, they could end up with a denied claim. In such a case, the insurer might argue the person was not hurt in the accident and could have probably sustained the injury from other causes later.
- Inadequate coverage – If the damages sought against the at-fault policyholder’s coverage exceed the limit, the insurer can deny claims.
- Expired policy – If the at-fault driver had not renewed their policy, their insurer has no obligation to honor the claim.
- Mistakes – Inaccurate information (e.g., data entry errors) can disqualify a valid claim. Other mistakes that could lead to denial may include giving deliberate false/exaggerated information, late submission, etc.
- Delayed reporting – If the claimant delayed in notifying the insurance company about the accident, the insurer might argue they were unable to investigate the accident and deny the claim.
- Policy exclusions – Some policies have exclusions for certain types of accidents. If the cause of the accident falls under the exclusions, it could lead to claim denial.
- Bad-faith denial – Sometimes, the insurance company can deny a claim for valid reasons such as inadequate evidence or late claim submission. However, there are instances where a denial could be in bad faith.
Step 2: Review the Insurance Policy
After understanding the reason for the denial, one should review the policy document to understand the provisions (limit, coverages, etc.) and the specific provider’s appeal guidelines. Ideally, the appeal request should address the particular reason behind the denial.
An appeal mainly involves challenging the insurance company’s decision by demonstrating why the claim is valid. To successfully appeal the denial, one must provide solid evidence countering the reason for the denial. For instance, if the rejection was due to disputed liability, getting CCTV footage of the accident scene (if available) or providing eyewitness or expert witness statements helps back up the claims.
Step 4: Write an Appeal Letter
The last step involves drafting the appeal, explaining why the claim should have been accepted. Every argument must be supported by evidence (photos, medical records, eyewitness statements, police reports, and other relevant information gathered during the investigation).
Usually, one can appeal claim denial multiple times, first to the insurer and later to the state insurance commissioner’s office.
What Kind of Evidence Should Be Provided?
The evidence required depends on the denial reasons. But generally, one should gather and submit all the proof necessary to demonstrate the liability of the at-fault party and the damages they have incurred due to their negligence. The information may include the following:
- Photos of injuries and property damage
- A detailed chronology of events (dates)
- Relevant records (doctor’s reports, receipts, invoices, etc.)
- Eyewitness statements
- Police reports
Raise Your Chances of a Successful Appeal
Besides understanding why the claim was denied in order to lodge an appropriate response, there are several measures one can take to raise their chances of a successful appeal. Here are a few examples:
- Submit the right paperwork – Using the appropriate paperwork (company appeals forms) can speed up the claim processing. The claim number and insurance ID number should also be correctly filled out.
- Get organized – Insurance companies work on piles of claims every day. For easier tracking of the process, it helps to get organized. For example, by requesting a call reference number, document image number, etc
- Manage emotions – Getting a claim denied can be frustrating, especially with piling medical bills. In such a situation, one can easily get angry and impatient with the representative handling the claim, though they might not be responsible for the denial. As frustrating as it may be, one must try to create a good rapport with the representatives they deal with as they can help speed up the process.
- Hire an attorney –A personal injury attorney experienced in handling car accident claims has the necessary knowledge and skills to handle the appeal. For example, they can examine the denial letter, investigate the accident, build solid evidence, and respond to the rejection appropriately. Unlike the insurance company, the attorney serves your best interests, and you can rely on their experience to raise the chances of a successful appeal.
Claim Denial Is Not Final
Having a car accident insurance claim denied can be frustrating. However, denial is not final. Sometimes some rejections are due to data entry errors such as using the wrong insurance ID number, misspelled name, etc., while others require gathering more evidence to prove liability. Generally, a claimant has multiple opportunities to appeal the decision, first with the insurance company and then with the state insurance commissioner’s office if the insurer remains adamant.
In cases where a settlement cannot be reached out of court, one can file a lawsuit, like in the 2018 Fox V. Mize case.
If you have been injured in a car accident, our expert team can help you get the compensation you deserve. Contact us or call us at 918-359-6600 today for a free consultation.