Insurers, whether they provide car, home, or health coverage, are duty-bound to fulfill their policies on request. The only reason an insurance company would legally deny a claim is if the damage falls outside their coverage, or if the insured person did something that voided or breached their insurance policy—for instance, causing intentional harm or committing fraud. Otherwise, insurers are legally required to a.) investigate claims quickly, and b.) pay out on valid claims.
Why Insurance Policies Get Wrongfully Denied
In practice, however, insurers deny valid claims all the time. Sometimes it’s an honest mistake, where the company makes a simple error via an incorrect code or filing. In some cases, insurance companies may have policies that purposefully force claimants to slog through punishing bureaucratic processes before getting what they need. After all, insurance companies are publicly traded for-profit organizations—the fewer payouts they offer, the better they perform financially.
But in either case, an insurance denial comes at the worst possible time. Whether you’re dealing with a sudden illness, personal injury, or home damage, you need your insurer to come through for you. If they don’t, it might leave you on the hook for hundreds of thousands of dollars in damages, on top of the thousands of dollars in premiums you’ve been paying all these years.
Prepare the Insurance Appeal Letter for an Internal Review
There are stages to an insurance appeal: the internal stage and the external stage. In order to make a proper appeal for the internal stage, you’ll need to abide by the specific procedural requirements set by your insurer. Frankly, they can be a little opaque for first-time claimants. More generally, you’ll need to appeal on the basis of your benefits under your policy and how your claim entitled you to those benefits.
For that, you may need:
- Evidence that proves the validity of your claim
- The paperwork associated with your original claim
- Your denial letter
- Evidence that addresses the points of your denial letter
These documents will differ according to the type of insurance claim you’re appealing. For a health insurance claim, your additional evidence may include a second opinion from a specialist to explain why your procedure was necessary (and thus covered). For an accident claim, it may require getting a copy of the police report or footage/photos of the damage you suffered. For a serious accident, you may need both to justify both medical and financial benefits.
Getting an Attorney to Prepare the Insurance Appeal
If the internal stage doesn’t yield you the results you need, you’ll need to escalate your appeal to an independent third party who can make a ruling on the claim. We won’t lie to you—this entire process is complex and difficult for first-timers. Insurance companies design these procedures to be highly technical, difficult to navigate, and intimidating to someone unfamiliar with insurance law. They’re counting on you to quit or accept a lowball settlement.
The best way to level the playing field between you and your insurer is to hire an insurance claims lawyer. An attorney has the skill, experience, and track record to force your insurer to take your claim seriously and abide by the law. An especially skilled attorney can get the full value of your policy, as well as potential damages if your insurer is found to have deliberately hindered your claim, which is illegal.
Handler, Henning & Rosenberg LLC has won tens of millions for our clients, and we’ve been taking on insurers since 1922. Call (888) 498-3023 today for a free consultation to discuss your options.