If you were injured due to someone else’s negligence, whether that means you were hurt in a car accident or a slip-and-fall accident on someone else’s property, you might have filed a claim with the responsible party’s insurance company. If the insurance company has denied your claim, you might feel this is the end of the road. At Cousin Benny Personal Injury, we know this is often not the case. In many personal injury cases, a claim denial is only the first step in a long journey to recover compensation for your injuries.
An experienced personal attorney from Cousin Benny Personal Injury can help you understand insurance claim denials and your legal options. Contact us today for a free consultation.
What Is an Insurance Claim Denial?
When someone has an accident that is covered by an insurance policy, they turn to the insurance company to compensate for their damages. However, the insurance company can review the claim and deny it.
A denial from an insurance provider is a refusal to pay for a claim. This may be a denial of a portion of your claim, such as medical expenses, but not property damage, or all of the claim.
It is important for claimants to understand that insurance companies are for-profit companies. They make a lot of money by collecting more premiums than they pay in claims. Therefore, they will look for every way possible to avoid paying claims in order to protect their profit margin.
Why Do Insurance Companies Deny Claims?
Unfortunately, there is no shortage of reasons why insurance companies may deny claims. Some of the most common excuses that our personal injury lawyers have heard include the following:
The Loss Is Not Covered Under the Policy
Insurance companies may claim that the loss is not covered. For example, this issue can arise in a car accident case. Pennsylvania operates under a choice insurance system. Here, insured individuals choose whether to select limited tort or full tort in the event of an accident.
Under limited tort, car accident victims cannot recover compensation for pain and suffering or other damages unless they suffer a serious injury, as defined by state law, or a specific exception exists. Therefore, if you request pain and suffering damages, the insurance company could try to deny this portion of your claim if you have limited tort insurance.
A Policy Exclusion Applies
Insurance policies might exclude various types of injuries or claims. For example, if you were driving a vehicle that you were specifically excluded from, the auto insurance coverage may not apply to you. Common exclusions might include:
- Excluded drivers
- Acts of God
- Injury occurring during an excluded activity
- Intentional harm involved in the event
However, some exclusions are so minute and buried in the fine print that they may not even be noticeable or legal. An experienced attorney can carefully review the insurance policy in question to determine if this is a valid ground for a denial or just a ruse to deny the claim.
There Was an Expiration or Lapse of Coverage
In some accidents, insurance coverage might not apply because the insured’s policy had
recently lapsed. They may have forgotten to make a payment or renew their policy, causing a lapse in coverage. In such cases, you might need to consider another pathway for compensation, including filing under your own insurance policy or locating another responsible party.
Insurance Coverage Was Insufficient
Insurance companies will only agree to pay up to policy limits. In Pennsylvania, the minimum liability insurance limits are:
- $15,000 in bodily injury per person
- $30,000 in bodily injury per accident
- $5,000 in property damage liability
Therefore, the insurance company might only pay up to the policy limits or even try to negotiate for less than that. This can be problematic when injuries are severe, such as in pedestrian accidents, bicycle accidents, or motorcycle accidents.
If the at-fault driver had no or insufficient coverage, you might be able to file a claim with your own uninsured or underinsured insurance coverage, respectively.
Liability Is in Dispute
Another common reason for personal injury claims to be denied is that there is a dispute over
liability. For example, if you are injured in an auto accident, the other driver might claim that you are at fault for the accident instead of them. Pennsylvania is an at-fault state for car accidents, so the at-fault driver is responsible for paying for the damages that they cause. Under Pennsylvania’s modified comparative negligence law, you are barred from recovering compensation if your degree of fault is greater than the defendant’s degree of fault.
This cause for claim denial can apply in other situations because most personal injury claims are based on the legal concept of negligence. With this legal doctrine, you must be able to prove that the defendant did something that violated their duty of care that caused your damages. For example, if you slipped and fell in a grocery store, you would have to be able to point to a dangerous condition that the property owner knew about or should have known about but failed to correct.
Even if you are not found completely at fault for the accident, insurance adjusters might still try to use disputed liability to justify denied claims. You may have to file a personal injury lawsuit to sort out the liability issue before a judge or jury. It is your burden of proof to show the defendant’s legal accountability.
The Accident Victim Had a Pre-Existing Condition
Some insurance adjusters justify claim rejections because the accident victim had a
pre-existing condition. They may obtain medical releases from victims to request years of medical records to try to find some previous accident or medical condition to blame for the victim’s current injuries.
While some accident victims accept this reason, this is not the law in Pennsylvania. Here, accident victims have the right to recover compensation if they suffered a new injury or if their previous injury was exacerbated by the accident.
The Claimant Had a Gap in Medical Treatment
Similar to the last reason, the insurance company may try to justify a claim denial by arguing that the victim did not seek immediate medical treatment. This gap in medical care may give them plausibility to deny the claim since the victim could have been injured by some other cause during the gap.
However, some personal injuries are not always immediately apparent. An experienced personal injury lawyer can gather your medical records and help argue for the compensation that you deserve.
There Is Not Enough Medical Proof
Another potential cause for an insurance claim denial is that there are limited or no medical
records. The insurance company could argue that there was no injury if there were no objective medical records to review. Remember, insurance companies are focused on their bottom line, so they will try to justify denials for any reason, including incomplete, missing, or ambiguous medical records.
The Claimant Missed a Deadline
Missing a critical deadline in a personal injury case could be disastrous for a claimant. Some
insurance providers require their insured to report all accidents to them within a short period of time. If the insured fails to meet this deadline, the insurance company could try to deny the claim.
Another issue that personal injury victims face is that the statute of limitations can run out before they file a lawsuit. Statutes of limitations require parties to take certain legal action within a specific timeframe to preserve their rights. For example, personal injury lawsuits in Pennsylvania must generally be filed within two years of the accident. If the victim fails to file their case within this timeline, they can forfeit their right to recovery.
The Claim Is Incomplete or Incorrect
The insurance company might argue that the claim has inaccurate or incomplete information to justify the denial.
The Claimant Failed to Mitigate Injuries
The failure to mitigate damages refers to the plaintiff’s requirement to avoid taking action that makes their damages more significant than they should be. For example, if the victim did not follow their doctor’s orders and their injury worsened, the insurance company might argue that they should not be responsible for paying for the victim’s injuries.
Third-Party vs. First-Party Claims
Insurance claims may be first-party or third-party claims, which may impact how the insurance claim process unfolds and the way that the victim is treated. A first-party claim is one that you file with your own insurer, while a third-party claim is one that you file with someone else’s insurance provider.
Some people may feel that it is easier to handle a first-party claim than a third-party claim since they are dealing with their own insurance company. They may feel that the insurance company is more incentivized to deal with them respectfully or risk losing their business. Other insurance companies may seem more inherently adversarial in comparison.
Your own insurance company has a legal duty to act in good faith when handling your claim, giving rise to a bad faith claim if it violates this duty. However, many accident victims still feel like they are mistreated even when dealing with their own insurance provider.
The appeal process may also differ between first-party and third-party claims. Your contract with your insurance provider will set out this process, as well as any requirement to engage with alternative dispute resolution methods rather than litigating your case. For a third-party claim, you might jump straight to a lawsuit against the insurance company and/or at-fault party.
What to Do If Your Insurance Claim Is Denied
If you believe that your insurance claim was unfairly denied or denied in error, take these steps to protect your legal rights:
Carefully Review the Denial Letter
Reviewing the denial letter should always be your first step. The letter should state the
exact reason for the denial. If you don’t understand the reason for denial or no reason is given, contact the insurance adjuster assigned to your claim.
Compare the Letter to Your Insurance Policy
Next, compare what the letter says to your insurance policy. Don’t take the insurance claims
adjuster’s word for it. Compare the specific policy provisions to what the insurance adjuster says. Many times, the insurance adjusters cite provisions that don’t exist or intentionally misinterpret what they mean to work in their favor. Also, review your policy for any information on deadlines regarding internal appeals so that you don’t miss a critical deadline in your case.
Gather Additional Evidence
The claim may have been denied because the insurance company claims that it did not receive sufficient information to process the claim. Gather more evidence to support your claim, including:
- Accident reports: Gather police reports, witness statements, and incident reports that detail the accident and how it happened.
- Medical records: Keep all medical bills and records, including hospital bills, doctor’s notes, bills for rehabilitation treatments, proof of medical expenses, and other evidence of the medical treatments you went through because of the accident.
- Correspondence: Keep a detailed record of all of your communications with the insurance company, including the date of communication, the person with whom you spoke, and what was said.
- Proof of liability: You may have photos of the accident, vehicle damage reports, or other evidence that points to liability that you could share.
Request Your Claim File
Contact the insurance company and request your entire claim file. You can provide it to your personal injury lawyer once you receive it.
Contact Our Personal Injury Attorneys
Contact the experienced and compassionate personal injury lawyers at Cousin Benny. Our attorneys can review your claim denial, the insurance investigation, and your case. We can identify your legal options, which may include filing an internal appeal, modifying your claim, or filing a personal injury lawsuit to pursue the compensation you deserve. Contact us today to take the first step toward protecting your legal rights.