If you’ve suffered injuries in an accident, you probably expect the at-fault party’s insurance provider to handle your claim fairly.
However, insurers deny a surprising number of legitimate personal injury claims every year. Victims are often left confused, overwhelmed and empty-handed.
In this article, we’ll lift the veil on common reasons insurance companies reject or undervalue injury claims. The goal is to shine a light on unethical tactics used by insurers to avoid paying out full compensation. Victims can identify questionable denial reasons more easily so they can challenge them.
Top Reasons Insurance Companies Wrongfully Deny Claims
While insurers cite various technicalities, most denials boil down to a few key factors. Here are the main reasons your insurance claim might be denied:
Pre-Existing Conditions
One reason an insurer may deny a personal injury claim is if they believe the injury or damage existed prior to the policy start date. For example, if you file a claim for a ruptured disc after a car accident, but you had back problems before buying auto insurance, the company could argue it is a pre-existing condition unrelated to the crash.
To protect against this, document prior injuries and treatments with your doctor. Be upfront about medical history when applying for coverage. Save records showing the condition was stable before the accident.
If denials still occur, Ohio law provides consumers the right to appeal. An attorney can request a “pre-existing investigation review” on your behalf.
Paperwork Errors
Even simple paperwork mistakes can lead to denied claims. Common errors include missing information on forms, illegible handwriting, or submitting to the wrong department. This is particularly prevalent with complex health insurance claims.
Stay organized and keep copies of everything submitted. Confirm claims are received and follow up on status. Ask for help completing forms if needed. Should a denial occur due to correctable errors, resubmitting with clarifications can often resolve the issue.
Questionable Medical Necessity
Another reason insurers deny coverage is by deeming services “not medically necessary.” This is common with health plans but also applies to auto and disability policies. Treatments may be considered excessive or experimental.
To show medical necessity, get your doctor’s opinion in writing explaining how care directly relates to the accident and injuries. Get second opinions supporting the treatment plan. Reference recognized standards and guidelines. Appeal denials promptly and be prepared to negotiate if some treatment is less critical.
Lapsed Premium Payments
Insurers will deny claims if policy premiums are not paid when due. Even with grace periods, a lapse in payment can occur if you changed credit cards or missed notices. Auto-pay errors also lead to lapsed payments.
Avoid this scenario by clearly tracking due dates and payments. Sign up for premium reminders from your insurer. If a lapse occurs, act immediately to reinstate the policy if allowed. Provide proof of payments made to show the denial was unwarranted.
Late Reporting
Insurance policies include time limits for reporting claims, often as short as 24 hours. Failing to report accidents or damage promptly can lead to automatic denial of claims.
Sometimes, extensive damages are not immediately apparent, like with some medical issues. Other times, fear of rate increases may delay reporting. Regardless, late reporting remains a common reason for denial.
To avoid this, report incidents and injuries ASAP, even if unsure about pursuing a claim. Photograph damage right away. Save medical records diligently. If a denial still occurs, appeal based on “extenuating circumstances” with documentation to back up late reporting.
How to Appeal a Denied Insurance Claim
If a claim is denied, don’t assume you’re out of options. Every policyholder has the legal right to appeal, but the process must be handled properly.
Here are some tips:
- Review the denial letter for reasons given and focus appeals on disputing those points.
- Note all deadlines for appeals and document submission. Missing deadlines can ruin the appeal.
- Request a “second review” from the insurer, as most offer an internal appeals process.
- Submit additional information such as accident reports, medical records or expert opinions.
- Escalate to state regulators if needed. In Ohio, contact the Department of Insurance for assistance.
- Consult an attorney for guidance, especially for denials involving serious injuries or large claims.
While appealing denials takes effort, over 50% of appeals ultimately overturn the denial. With persistence and documentation, many claims can get approved.
Is It a Case of Insurance Bad Faith?
Most claim denials have a reasonable basis, but occasionally, an insurer crosses ethical lines into “bad faith” territory. Under Ohio law, insurers must act in good faith when handling claims. If an investigation shows that the denial was unfounded or conducted negligently, you may have a bad faith claim against the insurer.
Some signs of potential bad faith include:
- Denying a claim knowing the reason is invalid
- Failing to investigate a claim properly before denying
- Delaying the review process excessively
- Not communicating with the policyholder
- Misrepresenting policy terms when denying
Proving bad faith is complex, but the payouts can be significant. On top of the denied claim, additional compensation for economic and emotional damages may be awarded. Consult an attorney to determine if your denial warrants a bad faith investigation.
How An Attorney Can Help With Denied Insurance Claims
The Jones Firm in Columbus, OH, has extensive experience appealing and litigating denied insurance claims. They take an aggressive approach against insurers wrongfully denying coverage.
If your claim is denied, contact their Columbus office at https://www.jonesfirmohio.com/ for a free case review.
Their personal injury attorneys will evaluate your denial, advise your options, and fight to get you maximum compensation. With their help, you can fight back and recover the benefits you deserve.
