Appealing an Insurance Claim Denial

May 28, 2019 | Attorney, Matthew Dolman
Appealing an Insurance Claim Denial After an accident, you generally assume the insurance company will honor its promise to cover your losses and expenses. After all, you pay your insurance policy each month. Maybe you even picked your insurance company based on advertisements about how it pays claims quickly, or based on their supposed “effortless claims process.” You participated freely in the investigation and provided all the necessary paperwork to your insurance company. Then the news comes back: claim denied. What comes next? By understanding the steps involved in appealing an insurance claim denial, you may change the outcome and get the funds you deserve for your accident in your hands sooner.

What Happens During a Claim Investigation?

Soon after you file a claim with your insurance company, your insurance adjuster will contact you. The adjuster will discuss the conditions of your accident and how your injuries occurred. He may want you to submit:
  • The police report
  • Medical reports related to the accident
  • Any information collected from the scene, including contact information for witnesses
The adjuster will then review your policy and discuss what it may cover with you. Make note of anything the adjuster says during this process: while it may not guarantee the coverage you will ultimately receive, it can help give you an idea of what to expect. Next, the adjuster may want to look for more information. This might include checking witness statements, examining traffic cameras, and sending your car to a garage. At the garage, mechanics will determine how badly you damaged your vehicle and how much repairs will cost. The insurance company will then decide whether to repair the vehicle or total it. If you sustained injuries during the accident, the adjuster may also want to view your medical reports. They may check out information from the hospital or ask for forms from your doctor. You need to return these forms to your adjuster as soon as possible. Failure to submit these forms can result in a claim denial.

Claim Denied: What Next?

If you receive a claim denial from your insurance company, first, look at the reason for the claim denial. There are several reasons your insurance company might deny your claim:
  • The policy holder (you) did not cause the accident.
  • Less damage occurred during the accident than claimed. This includes instances when you claim more significant injuries than you received during the accident.
  • Another event, not the accident, caused your injuries.
  • The driver is not covered by the policy. Any time a new teen driver enters the household, for example, you must notify your insurance company. If that teen causes an accident and you did not notify the insurance company, the company may deny your claim.
  • The insurance company does not cover a specific use of the vehicle, including using it for job purposes. If you worked as a pizza delivery driver or an Uber or Lyft driver at the time of the accident and did not notify your insurance company ahead of time, the company may deny your claim.
  • You failed to notify the insurance company about the accident. Some insurance companies include a statute of limitations in their policies. The company may also deny the claim if you failed to provide them with adequate information about the accident in a timely manner.
  • You deliberately caused damage to your vehicle. For example, if you knew that your vehicle needed expensive repairs and you chose to attempt to total it instead, the insurance company may deny your claim.
  • Your accident fits within specific policy exclusions. Your insurance company must explain the reason for the claim denial to you and indicate what exclusion your accident falls under.
  • Policy coverage lapsed. If you lost track of your last insurance payment, your coverage may have lapsed temporarily. Generally, your insurance company will allow you to “catch up” and reinstate this coverage; however, if an accident occurs while your policy has lapsed, you may not receive coverage for that damage.
If your insurance company denies your claim, you need to file an appeal. Try:
  • Asking your adjuster. Typically, the adjuster will tell you about the process to file an appeal. They may offer information about the likelihood of an appeal succeeding in your particular case, or they may not.
  • Asking for a supervisor. Before jumping to conclusions, go beyond your adjuster and ask to speak with a supervisor. Often, a supervisor can provide you with insight into why a claim was denied and whether you have grounds to take things further. In some cases, working with a supervisor can help you better understand why the company denied your claim—or the supervisor may quickly clear up any misconceptions.
  • Checking the website. Many insurance companies now allow you to follow the claims process online. By checking the website, you may easily appeal your claim when the company denies it.
  • Contacting a lawyer. If you do not already have a lawyer for your accident case, get in touch with an experienced, dedicated attorney as soon as possible. The sooner you call, the sooner a lawyer can start working on your behalf. A lawyer can help you determine when to draft a letter of appeal, what information your file might not have, and when to contact the state insurance adjuster.

Claim Denials: Bad Faith Insurance Claims

According to Florida statute 624.155: Any person may bring a civil action against an insurer when such a person is damaged: (b) By the commission of any of the following acts by the insurer: 1. Not attempting in good faith to settle claims when, under all the circumstances, it could and should have done so, had it acted fairly and honestly toward its insured and with due regard for her or his interests. In a bad-faith insurance claim, the insurance company may simply refuse to pay or even investigate the terms of a specific claim. In spite of policies that are updated and paid in full, the insurance company may refuse to pay the cost of hospitalization, property damage, and lost time at work following an accident. A bad faith claim may include:
  • Failing to properly investigate a claim. The insurance company may, for example, fail to take evidence into account when deciding who bears fault for an accident, or they may fail to look into the details of the claim.
  • Misrepresenting your coverage. In many cases, insurance policies include complex language that you may struggle to follow. Representatives of the company may use this complex language to confuse you, insisting that your policy does not offer the coverage you think it does.
  • Acting in the best interests of the insurance company, rather than the insured. Insurance companies must, according to Florida law, act fairly and honestly toward the people they insure, including paying out claims within the limitations of the policy. Unfairly handing out these claims, including claim denials for no reason, does not represent the best interests of the insured—in this case, you.
  • Altering the terms of the policy without notifying the insured. In some cases, insurance policies may change after the creation of your initial policy. If these terms change, however, you should receive due warning, including written communication about the terms of the change. Generally, any shift in coverage should occur at the end of a contract, rather than in the middle of a coverage period.
  • Failing to offer a reason for a claim denial. Your insurance company may legitimately deny claims for a number of reasons. In order to legally deny a claim, however, the company must offer an explanation for the claim denial that fits within the terms of your policy.
  • Failing to communicate clearly with the insured throughout the process. In some cases, for example, an insurance company may need more information to process a claim. Rather than denying the claim, the company must communicate that need to the insured and provide them with adequate time to provide the requested information. The company should issue these requests in writing using clear, understandable language. The company should also clearly explain why the information will help process the claim.
Under Florida law, the insurance company has 60 days to make good on the claim. If they make things right and issue the payment, you no longer have a bad faith claim.

Common Signs of a Bad Faith Claim Denial

Did your insurance company deny your claim? Look for these signs of a bad faith claim denial:
  • The investigation process stretches out unnecessarily, with no good reason or explanation given.
  • Your insurance company fails to provide you with a reasonable explanation for the claim denial. This includes a claim denial with a reason that does not make sense as well as a claim denial with no reason.
  • The adjuster applies pressure to accept an offer immediately, even when you think the offer too low.
  • Your insurance company failed to notify you about changes to your policy. For example, you might have assumed you had one type of coverage, but found out when you filed your claim that you did not.
  • Payment for your claim takes too long to process without a valid reason.

Still Denied: Now What?

Your lawyer wrote a letter of appeal, and you followed the necessary steps to appeal your claim. Unfortunately, the insurance company still denied your claim. You still have options that can help you get the funds you deserve:

Contact the State Insurance Regulator

When you receive a denial for your insurance claim in spite of the fact that your accident should receive coverage, a lawyer may guide you to the state insurance regulator. This contact should generally occur after an appeal is denied, but before taking your case to court. The insurance regulator will need all the information about your accident, including both your statement of events and all the evidence you have collected. The insurance regulator will also need to see a copy of your policy.

Go to Court

If the insurance company denies your appeal and does not listen to the state insurance regulator, you may need to take your case to court. Working with an attorney can help you better determine when you need to take the case to court and when you need to settle for what the insurance company offered you.

How Working With a Lawyer Can Help

If you file an insurance claim and have it denied, you may need a lawyer to help you file your appeal and gather the right evidence to increase your odds of a successful appeal. Consider these benefits of working with a lawyer:

A lawyer can help you better understand how much you deserve.

Was your claim too high for the type of accident you suffered? Did you try to ask for coverage for things that the policy fails to mention, leaving your entire claim denied? When you work with a lawyer, you will receive valuable advice about exactly what you should ask for and what you should expect from your insurance company.

A lawyer can help you better review the insurance policy.

Different insurance companies offer different policies to their customers. Unfortunately, you may suffer confusion and struggle to understand the policy. Why does the policy not cover your injuries? Why is the coverage amount inadequate? A lawyer can review the policy and explain it to you in a way that you will understand, rather than leaving you floundering on your own. Not only that, a lawyer can help you review the policy to look for any loopholes or to better understand why the company denied your claim.

A lawyer can fight for you.

If your case must go to court or negotiations with the insurance company take too long, a lawyer can help fight for you and ensure that your rights are taken into consideration. You paid for your policy. A lawyer can help you defend your rights under it.

Do You Need Legal Help After an Insurance Claim Denial?

The sooner you seek legal help after your accident, the better. Your lawyer can help you collect evidence more easily immediately after the accident when the events remain fresh in your mind and in the mind of your witnesses. Some people, however, do not realize they need legal help until the insurance company denies the claim. If you recently received a denied claim, don't wait! Contact Dolman Law Group Accident Injury Lawyers, PA, today at 833-552-7274 (833-55-CRASH). With offices in Clearwater, St. Petersburg, Sarasota, and New Port Richey, we have a dedicated legal team close to you. Dolman Law Group Accident Injury Lawyers, PA 800 North Belcher Road Clearwater, FL 33765 (727) 451-6900


Matthew Dolman

Personal Injury Lawyer

This article was written and reviewed by Matthew Dolman. Matt has been a practicing civil trial, personal injury, products liability, and mass tort lawyer since 2004. He has successfully fought for more than 11,000 injured clients and acted as lead counsel in more than 1,000 lawsuits. Always on the cutting edge of personal injury law, Matt is actively engaged in complex legal matters, including Suboxone, AFFF, and Ozempic lawsuits.  Matt is a lifetime member of the Million Dollar Advocates Forum and Multi-Million Dollar Advocates Forum for resolving individual cases in excess of $1 million and $2 million, respectively. He has also been selected by his colleagues as a Florida Superlawyer and as a member of Florida’s Legal Elite on multiple occasions. Further, Matt has been quoted in the media numerous times and is a sought-after speaker on a variety of legal issues and topics.

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