Insurance claim denials are when your insurer fails to approve your claim after processing it. It can feel more final because, unlike with rejected claims, you can’t correct the claim and resubmit it to your insurer.
It can be stressful to deal with this situation, because you might not know how to proceed to get coverage for your claims.
Hiring a lawyer from ContractsCounsel, an online legal network connecting vetted lawyers with clients, makes the process easier and helps you turn denied claims into paid ones.
There are other things you can do. Read the rest of this article to explore the top reasons why insurance claims get denied, what you can do to prevent denials, the action to take when your claim is denied, and how a lawyer can help you.
Why Do Insurance Claim Denials Occur?
Although insurers can deny claims for several reasons, here are the most common ones that occur.
- Lack of medical documents. If you don’t provide comprehensive and appropriate medical or other documents, there’s a good chance your insurance company will deny your claim.
- Pre-existing medical conditions. If you’re claiming for an injury or condition that medical insurance argues was already present prior to your claim, they might deny it. Should they find pre-existing conditions you haven’t mentioned, this could confirm their decision to deny your claim.
- Not reporting quickly. If you’ve taken a long time to submit the claim, your insurer might argue that you haven’t stuck to the deadlines.
- Coverage exclusions. If your claim isn’t covered by your policy, this will prevent you from being paid.
- Bad faith. In some cases, insurance companies might deny your claim because of bad faith practices, such as delaying or denying valid claims on purpose.
What Should You Do to Prevent Insurance Claim Denials?
To prevent your insurance company from denying your claims, you can protect yourself by ensuring you follow these tips.
Review Your Insurance Policies
You should refer to your insurance policies every year so you’re aware of what your policy will cover and what’s excluded.
Keep a Record
Whether you’re dealing with medical, car, or property insurance, you should keep track of all receipts or records. This will ensure you have all the information you need to submit comprehensive claims that are more likely to be approved.
Report Claims Quickly
You should aim to report all claims to your insurance company as soon as possible so that you reduce your risk of them being denied.
Check your specific policy to learn how long you have to submit a claim. The document will also give you information about what kind of information you need to submit with your claim.
What Should You Do if Your Insurance Claim is Denied?
There are important things you should do if your insurance claim gets denied.
Read the Denial Letter
When your claim gets denied, your insurance company will send you a letter explaining the denial. They might mention a policy exclusion or that they require more documents.
In some cases, such as the request for additional information, you can rectify the situation yourself. Otherwise, you can appeal the denial if your insurance company has an internal appeal process.
Send a Written Appeal
In this letter, you should clearly explain to your insurer why you think it was incorrect for your claim to be denied. Include as much information as you can to support your case. This can include mentioning policy terms that confirm your coverage or providing documentation.
If you don’t get a response or your appeal is denied for the second time, you can take matters further by contacting your state’s insurance regulator. This is especially useful if you think you’re dealing with a bad faith practice.
Get an External Review
If you’ve submitted an appeal but your insurer still doesn’t approve it, you have the option of requesting an external review. This is conducted by a neutral third party and it can help you to keep the insurance company accountable. Your insurance company will have to comply with the reviewer’s decision on the case.
Hire a Lawyer
If your insurance claim has been denied and you have to appeal it, you could do with the support of a lawyer from ContractsCounsel. Here are ways in which they will help you throughout the process.
Your Lawyer Will Draft Important Documents
When you have to send an appeal letter, your lawyer will help you by informing you of what you need to include and what timeframes you have in which to submit it. This can be a huge help to strengthen your case.
Your Lawyer Will Review Your Policy
Some insurance policies can be vague, confusing, or filled with complex wording. These can make them challenging to understand and review if you don’t have a legal background.
Your lawyer will review your policy and explain your rights, the medical insurance company’s duties, and how the terms and clauses in the document can validate your claim.
Your Lawyer Will Negotiate on Your Behalf
Your lawyer will get in touch with the insurance company and try to settle the issue of the denied claim. They can also engage in mediation to try to reach a settlement that provides a favorable outcome.
Your Lawyer Will Gather Important Documents
Since lawyers know what insurance companies look for and how they operate, they’ll help you to gather all the right documents to prove that your claim should be approved, such as medical records, witness statements, and repair bills.
Your Lawyer will Represent You
Many claim-denial disputes will go through mediation or arbitration before litigation. Your lawyer will help you by advocating for you throughout all these processes, helping to support your case and reach a settlement with the insurance company.
Do you need a lawyer for an insurance claim denial?
Contact a lawyer on ContractsCounsel. All lawyers are vetted on the platform, and they have years of experience and legal expertise to help you through every step of the claim denial dispute.
