How Do I Challenge an Insurance Claim Denial?

Jun 15, 2022

How Do I Challenge an Insurance Claim Denial?

In an event involving damage to your health, home, or vehicle, the safety net provided by your insurance agency can be the source of stability you need to get your life back on track. From home and auto insurance to health and life insurance, the knowledge of being covered is great for helping you through tough times. However, insurance agencies may refuse to pay certain charges or flat out deny certain services, leaving you to deal with the financial fallout from these decisions. Luckily, challenging a claim denial is possible, and with the right approach, you can receive your necessary coverage.

What Is an Insurance Claim?

An insurance claim is a request for payment sent to your insurance agency, asking them to pay the cost of any procedures or repairs related to your injury or accident. For example, if you fall and break your leg, you would send out a personal injury claim to your health insurance company asking them to pay your hospital bill. Depending on the circumstance, as well as what charges need to be covered, insurance companies can either pay the bill in full, partially cover the costs of the incident, or end up not covering the damages depending on certain restrictions or clauses in your individual claim.

How Do You File an Insurance Claim?

Filing an insurance claim starts with contacting your coverage provider as soon as you’re able to after the incident. For example, if you get into a car accident and need repairs on your vehicle, contact your insurance agency and begin the claim filing process as soon as possible. For some insurance agencies, contacting them through a mobile app or online service is part of the claim filing process. Regardless of the contact method, getting in touch with your agency and filing a claim is imperative to the insurance claim process.

How Does a Claim Get Denied?

In some situations, insurance claims can get denied by larger insurance agencies for different reasons. Using health insurance as an example, your insurance company may deny a certain service as not being covered by your plan, deeming it “medically unnecessary.” In some situations, these claims may be denied due to an internal error, which can be fixed after reaching out. However, if your claim is denied and no reasoning supports their final verdict, this agency is said to be acting in bad faith, and additional damages resulting from the denial of coverage can be incorporated into your claim.

What Are the Ways to Challenge a Claim Denial?

Once your claim is denied, gather any evidence, documents, and conversations with your provider that can help provide the basis for your repeal. At this point of the process, reaching out to your provider, with your evidentiary support, helps formulate a case against your provider, giving you a sense of clarity as to why your claim was denied. There are two main routes for filing an appeal, which includes:

  • Internal Appeals: An internal appeal is a kind of investigation run by your insurance provider that seeks to find the reasoning behind the denial of your claim. These appeals need to be filed within 30 days of receiving notice that your claim was denied, and in that time, it is helpful to collect any information about the denial as part of your record-keeping. Depending on the urgency of your case, asking for an expedited internal repeal, as well as increased contact with your provider, can help you settle the dispute promptly.
  • External Appeals: Depending on the nature of your claim denial, an external review might be the best option for investigating why you were denied coverage. An external review leaves the claim investigation process in the hands of a third party, who then determines whether or not your claim is to be covered by your insurance carrier. In California, the Independent Medical Review Program (IMR) helps facilitate proper medical claim appeals and investigations, holding insurance companies accountable for their denial of coverage.

Depending on your claim, as well as whether or not your decision was delivered in bad faith, the appeal process can differ from case to case. In situations where a claim was wrongly denied, or an internal error on the coverage provider’s end causes a denial of coverage, an internal appeal and investigation may be the best solution to resolving the dispute. On the other hand, in situations where the coverage denial was not adequately outlined by the decision, an external investigation conducted by a third party may be more productive for your case.

If you believe that your insurance claim was settled in bad faith, the next step towards appealing that claim would be seeing legal counsel. As a result of an external investigation, proving that your insurance carrier committed either a breach of contract or tort, which proves that the denial of coverage caused you immediate harm, can be used as grounds for a lawsuit. Reviewing your documents, denial letter, and any supporting evidence on your end can help build a strong case that seeks to award you entitled coverage and compensation.

When to Seek Legal Assistance

Filing an insurance claim is necessary for getting the coverage you need, especially in times of duress. Medical coverage, auto insurance, and home insurance are all essential to keeping you and your family safe, so when these claims get denied, this can be detrimental to your financial security and overall wellness. Fortunately, in situations where your claim has been denied, the options for appealing the decision and getting answers for your insurance company’s verdict are accessible and can help clear up any confusion.

If you have filed an insurance claim and received an unjust denial of coverage, you may need to do a deeper dive into your insurance company’s reasoning to get the coverage you need. Fortunately, for those in the Newport Beach area, the legal team at Winthrop Law Group can help you seek the legal help you need to investigate your claim and get the answers you need. For more information visit our website and contact us today.