Having insurance provides a sense of security. If something happens to your health, your home, auto, or business, your insurance provider is expected to cover your losses. Yet insurance claims are often denied, creating confusion, frustration, and unexpected costs.
In extreme situations, a denial from an insurance company may require legal advice and intervention. For that, an experienced attorney is a key asset, someone who can navigate the complexities of coverage and who has knowledge of avenues for settlement.
Steps to Take With Your Insurance Company After a Claim is Denied
When an insurance claim is denied, you have the right to explore options before accepting the company’s decision. The first step is understanding why your claim was denied, and from there, following procedures for an appeal. Note that strict timelines often apply, so quick attention to the matter is essential.
Denying coverage is often linked to your policy terms and documentation issues. It’s imperative to read and understand your coverage as well as its limitations. Carefully read the letter of denial to understand if there’s simply paperwork missing from your claim or if the denial is more technical. Consider the following circumstances:
- Exclusions or limitations: the policy may not cover the type of loss you are claiming. For instance, health insurance often has geographical limits, such as out of area care, and auto insurance may be limited if there’s commercial use of a private vehicle.
- Procedural issues: Prompt and accurate reporting, such as including a police report with a claim for business losses from a burglary, are essential components of a claim.
- Verifiable claims: The company must receive sufficient evidence of your loss to approve a claim. Documenting the cost or value of personal items destroyed in a fire or including a doctor’s letter in a health insurance claim can make a big difference.
- Technical issues: It’s possible for an insurance company to interpret a submitted claim very differently from the way it was intended. A denial can result from attributing a loss to poor maintenance or normal wear and tear rather than a catastrophic failure.
How to Proceed After an Insurance Denial
1. Carefully read the denial letter. Insurance companies are required to send a letter explaining the denial of coverage. This letter will also outline the deadlines and procedures for appealing the decision.
2. What does your policy say? The wording of your policy is a contract that lists covered losses, exclusions, and deadlines. Sometimes a denial can be appealed based on rewording, or the classification of the claim.
3. Review your documentation. Are there repair estimates, medical records, police reports, or correspondence that can be submitted in an appeal? Information provided by an expert, such as a certified technician, doctor, or fire investigator may sway an appeal in your favor.
4. Making an appeal. Most policies provide an opportunity for appealing a denial. It should be written in plain language, stating why you disagree with the denial and citing evidence (sent with the letter).
Resources for Wisconsin residents include the Office of the Commissioner of Insurance, which provides helpful tools for disputing denied claims. Contact the office to file a complaint if direct contact with the insurance company does not resolve the issue.
Issues with health insurance claims may be resolved for eligible Wisconsin residents through the Independent Review Process. This is an expert evaluation of the insurer’s decision, particularly in cases of medical necessity. The decision of the independent review process is binding for the individual and the insurance company.
In rare cases, insurance companies may act in bad faith, denying coverage without a reasonable basis. Such activity can give rise to a tort claim by the individual harmed. Proving wrongdoing is challenging, such as that the insurance company misrepresented policy terms, created delays or denied coverage without an investigation, made unreasonable demands for documentation, and/or offered a settlement far below what the policy provided.
Get Help Protecting Your Rights in Wisconsin
An attorney from Kerkman and Dunn, experienced in insurance issues and tort law, can review your case and intervene with an insurance company that refuses to pay a lawful claim. Don’t delay in asking for a consultation.
