How to Fight an Insurance Claim Denial
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Looking at the Appeals Process for Auto and Health Care Claims
Denials of Claims for Auto Insurance
Read your Policy - Review your Coverage
It’s important to understand how you are protected with respect to any insurance policies you hold, regardless of the coverage. Two areas that need special emphasis, particularly, with respect to filing claims are auto and health insurance. That’s because most of the claims that are denied are connected with the aforementioned coverages.
Examine your Policy
In the case of a denial for a claim for auto insurance, you will usually be sent a letter that gives the reason for the refusal. If you know what your policy covers, you should be able to decipher whether or not the denial is valid. Regardless, you’ll need to examine your policy to see if your insurer made an accurate determination.
Reasons for Denial of Claims for Auto Insurance
Auto claims can be denied for any of the following reasons:
- A claim was filed for uninsured motorist coverage but the other party in the accident was already covered.
- A claimant is not named in the policy as being insured – this may be true for teens who drive their parent’s car versus their own vehicle but are not insured under their parent’s policy.
- A claimant is not covered for the claim – this can occur if the insured is covered, say, for liability insurance, but didn't sign up for collision insurance. If he sustains damage to his car, then he will be denied.
- A file can also be denied if the claimant did not remit his premium payment within the allotted time and his coverage expired.
- Claims can be denied as well if the reported damage is above the limits set by your insurer.
- If the insured purchases a new vehicle and does not add the car to his insurance coverage within a designated period, his claim won’t be approved.
Using your Rights under the Law
The above examples are just a few explanations why auto claims can be denied. If you still feel, after scrutinizing your policy, that the reason for denial was inaccurate, then you can take measures to solve the problem. You are in your right, under state law, to have any legitimate claim request made to your insurer acknowledged and settled post-haste.
Step Number One – Write the Insurance Company
First of all, you’ll want to contact your insurer by writing the company and explaining the situation. Demonstrate, in your letter, where you believe they made their error. Attach the applicable documents to back up your statements. If a settlement does not result from this action, then you’ll need to make an appeal to your state’s Commissioner of Insurance.
Step Two – Make an Appeal to the Commissioner of Insurance
The office for the Commissioner of Insurance in your state regulates the activities of insurance companies as well as provides advocacy services for consumers. Therefore, they are, in essence, a complaint department for anyone who has a grievance with his insurer. If you make an appeal, you will need to provide substantial supporting documentation to defend your claim.
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Denials of Claims for Health Care
Health claims are another area where providers often deny claims. Many people, unfortunately, accept the decision without further investigation. That’s why it pays (literally) to know what your health policy covers as approximately ten percent of claims that are denied should never have been refused at all! In many instances, a denial may sometimes be based on a coding error, nothing more. Needless to say, understanding your coverage can go a long way toward resolving any disputes or clearing up any inaccuracies.
Keep in mind, too, that the insurance company, when denying a claim, should provide the following data:
- The name, title and license number of the individual who refused your claim.
- A statement which outlines, with specificity, the reason for denial, medically and scientifically.
- A statement which shows what part in the policy is the basis for denying the claim.
- A statement that describes any other treatment services or options that are covered in the policy.
Directions for making an appeal of denial and whether it must be in writing, along with the stipulated time for filing and the phone number of the person to contact for information and questions.
Directions for making a second appeal if the first appeal is refused.
If you don’t receive some or any of the above information with your denial, contact your insurer by making a request in writing to have all the required material sent.
Knowledge is Power
Knowing the above information, especially when disputing a denial for a claim, can make fighting a denial go just that much easier. Take into consideration too that most people who dispute what they believe to be an unfair denial, at least, according to statistics, usually win the case and, in many instances, get more than they asked for in the original claim. Therefore, it pays (once again, literally) to know what your health policy covers and take the steps needed to fight a claim that you believe was unreasonably denied.
Submit a Letter from your Physician
It’s essential, if you dispute a denied claim then, that you document everything – record all conversations and keep copies of all paperwork associated with the claim. Also, include a letter from your doctor. In the letter, he or she should convey the procedure or treatment that was performed, and where it’s covered in the policy. Mail the correspondence via certified mail and maintain all copies for your records.
Take the Following Steps –
In addition, the following steps are required to fight any unfair filing:
Make sure that the denial for your claim is in writing. Ask the insurer to provide a detailed explanation. Remember – mistakes on your part in the way the claim was filed are not reasons for a valid denial. Even if you were late in filing the claim, your claim cannot be denied simply for that reason.
If the claim was denied from an insurance company which you signed up under your employer, then take the matter to your human resources department and explain the situation to them. Back up your statements with supporting documents to show why your claim should be honored.
If you were denied a claim through an individual insurance company, contact your agent. He or she has an obligation, ethically, to assist in protecting your welfare.
Again, detail everything with respect to the claim. Record all conversations, the names of the people you contact and the date and time of each dialogue. Start by obtaining the name of the person who approved denial of the claim. Get the name of their supervisor and write him a letter regarding the claim issue. Make sure that you include copies of all the relevant forms and that you address the problem in cogent, succinct terms. Leave no stone unturned, so to speak – make certain you retain copies of all correspondence, conversations and documentation.
Should you not receive a reply, you’ll need to follow up by sending copies of the letter and material along with explanatory correspondence to the company’s president. (Under state law, insurers are required to reply straightaway to letters regarding claims.)
If the claim cannot be settled by any of the above-mentioned measures, then you will need to make an appeal or a grievance to the company. Generally, your appeal will be reviewed and you will receive a response within about a week. (Also, keep this fact in mind: If you are still denied and there was a change in your policy during the time of treatment or surgery, you may be able to still receive compensation if you weren’t given proper notice.)
Finding Relief Elsewhere
If the insurer, though, remains steadfast in his refusal to accept your claim, then you’ll need to report the matter to your state insurance commissioner and wait for a verdict before pursuing the matter legally.
Include conversations with anyone you talked to at your insurance company as well as details, such as date and time, for each discussion. A form is usually provided online that needs to be completed. Instructions with respect to required documentation will also be provided. After the Commissioner receives the details and information regarding your claim, he will send a copy of this data to your insurance company and ask them to respond. Upon their response the claim will be filed or your information may be given to a mediator who will be asked to assist you in seeking remuneration.
Step Three – Hire an Attorney
If, at this juncture, your claim has not been settled, you also have the option of retaining your own legal counsel. In response, as a last resort, you will need to sue the insurer for breaching their contract and for bad faith. It can be a lengthy process, but if you were unfairly treated, it’s the only remedy for obtaining the compensation you deserve for an accident claim.