Dealing with Insurance Claim Denial
When an insurance company denies your car accident claim, you should fight back. It’s up to you to take action following an initial denial. By the time a claim investigator formally refuses to pay for your bodily injury and/or property damages, he or she has already gathered enough evidence to support a denial position in court. The investigator may be open to negotiation eventually, but he or she will likely do nothing more until you take action. Once the investigator formalizes your liability denial, he or she may expect you to simply give up and go away.
Avoid Emotional Responses
When an insurance company denies a claim, anger is often an injured person’s go-to response. Anger is a reasonable gut reaction when you learn that an insurance company won’t pay for your injuries, but it doesn’t usually help reverse the decision. Insurance companies regularly deny claims. They’re used to anger, rants, and threats of future legal action.
Claims personnel prefer to avoid angry reactions, but such reactions rarely inspire them to change their position once they’ve made up their minds. Even the inexperienced adjusters recognize that you’re not serious about fighting back until you take the appropriate legal steps to recover your damages.
You Need a Legal Strategy
When an insurance company denies your claim, it likely considers it a success when you don’t fight back. Companies reconsider their position only if you provide new facts, additional evidence, or a legal theory that forces them to reexamine their original conclusion. Legally, insurance companies must maintain a reserve on their books, but the person handling your claim simply closes out your active file and waits for the statute of limitations to run. Insurance companies understand that many people choose not to fight back because the issues are complicated and the process is often challenging.
If you were seriously injured and believe another person is responsible for your injuries, you shouldn’t just walk away from a denial. When you contact Sibley Dolman Accident Injury Lawyers, we review your case and determine how we can help. We’ve worked with many injured victims, and we’ve helped our clients work through coverage and liability issues. We’ve also recovered damages from insurance companies who originally denied our clients’ claims.
You Should Know Why the Insurance Company Denied Your Claim
You can’t fight your claim denial unless you understand why the insurance company denied your claim in the first place. If you only have a vague idea as to why it won’t pay your car accident claim, you need more information, and you need it in writing.
Claim departments usually send out a letter explaining the rationale for a claim denial. If you didn’t receive a written explanation, contact the claim representative who denied your claim and request a letter outlining his or her decision. If you previously received a denial letter and you misplaced it, request a second copy. As denial letters often contain insurance jargon and complex legal phrases, you should consult with a personal injury attorney to help you understand exactly what the letter contains.
Insurance companies must comply with specific claim handling standards under Florida law. Many of the legal provisions govern the insurance company/insured relationship. As a third party beneficiary, some of the guidelines also apply to your liability claim, including:
- Insurers must implement proper claims investigation standards.
- Insurers can’t deny a claim without a reasonable investigation.
- Insurers must also acknowledge communications and act promptly.
Insurance companies deny claims for a variety of reasons. Whether they choose to pay or deny your claim, they must have evidence and coverage information to support their decision. When you provide information that disputes their conclusions, you force them to reconsider their rationale.
The Other Driver Was at Fault, but PIP Is Primary
In Florida, the liability carrier has no immediate duty to pay an injured person’s damages. When you sustain an injury in an auto accident, your own insurance company should pay your medical expenses and lost income under your own Personal Injury Protection (no-fault) coverage. If you’re a licensed driver or your vehicle is registered in Florida, you must carry the state’s mandatory minimum PIP coverage limits: $10,000 per person medical and disability benefits and $5,000 per person death benefits. You also must have $10,000 property damage liability coverage to pay for damage to vehicles and other property.
Even when the other driver is at fault, your PIP benefits are primary. Your insurance company pays 80 percent of your medical bills for treatment initiated within 14 days of the accident. Your PIP coverage also pays 60 percent of your lost income.
You have a right to make a liability claim against a responsible driver only if you sustain injuries as described by Florida law, which include:
- Significant and permanent loss of an important bodily function,
- Permanent injury within a reasonable degree of medical probability, other than scarring or disfigurement,
- Significant and permanent scarring or disfigurement, or
What can you do?
- You can present documentation that proves you’ve met one of the relevant injury thresholds. If the liability insurance carrier still denies your claim, its denial should address the additional issues that apply.
The At-Fault Driver Has Coverage Problems
A driver’s auto policy is a contract with his or her insurance company. To maintain coverage, the policyholder must pay the premium and comply with the terms and duties outlined in the insurance contract. A failure to do so is often a breach of contract that prompts a carrier to deny or void coverage.
If the auto liability coverage wasn’t valid on the accident date, the insurer has no duty to protect its former insured’s legal interests or settle claims on his or her behalf. Below are a few of the reasons why an insurance company might decline coverage to an insured individual for an accident.
- The policy doesn’t cover the date, time, circumstances, vehicle, driver, or other specific coverage requirements as outlined in the other driver’s policy.
- The policy expired or the insurance company canceled it for non-payment before the accident occurred.
- The driver or named insured failed to cooperate with the investigation.
- The claim department suspects fraud.
- The named insured or the driver jeopardized the investigation by delaying the initial claim report.
- The accident occurred during a specifically excluded action, such as an intentional act, while the car was being stolen, or while the driver was carrying passengers for a fee, such as with Uber or Lyft.
What can you do?
- If the other driver’s insurance company denies your claim based on a coverage issue, you have a minimal chance of recovering damages. Your chances increase if the policyholder decides to fight his coverage declination.
- If the other driver was working for a rideshare company, contact its corporate headquarters to determine if it has liability insurance to cover your accident.
- File an Uninsured Motorist claim with your own insurance company. UM coverage isn’t mandatory in Florida, but if you have it, your insurance fills the role of the at-fault driver’s liability carrier. The coverage pays for the damages PIP doesn’t cover. These include general damages, such as pain and suffering, scarring, and permanent impairment.
The Insurance Company Questions Liability
Insurance companies often deny claims due to questionable liability. One driver might give a different story than the other driver. In some cases, both drivers’ stories are the same, but the insurance companies interpret the facts differently. As Florida liability insurers pay injury claims based on pure comparative fault statutes, an insurance company should find it difficult to deny liability completely. In some cases, insurance companies may use questionable liability as a negotiation tool to coerce injured victims into settling for a low dollar figure.
Under pure comparative fault, an insurance company evaluates evidence to determine fault. The Comparative Fault statute recognizes that more than one person can be negligent when an accident occurs, so the drivers often share liability. When an insurance company settles an injury claim, it reduces the injured person’s damages based on his or her negligence percentage. Even if the insurance company decides that you’re 90 percent responsible for an accident, you should still receive 10 percent of your damages.
Occasionally, an at-fault driver claims that a vehicle defect or improper repair was the proximate cause of an accident. A liability insurance carrier may decide to deny liability, alleging that a manufacturer or repair company is solely responsible.
What can you do?
- You or your attorney can negotiate a settlement with the insurance company. As Florida’s comparative fault statutes allow flexibility in assessing liability, an insurance company understands that a court might see things differently. Even if the company believes that its insured has minimal or no liability, it may cost them more to actually try the case. The company will have to pay defense costs and may end up with a substantial verdict against its insured.
- Your attorney can file a product liability lawsuit: Vehicle manufacturers and repair companies are liable when their defective products or repairs cause an accident. A personal injury attorney can determine whether your circumstances will allow you to file a case based on breach of warranty, negligence, or strict liability.
The Insurance Company Questions Your Injury
Insurance companies deny claims when they question an injury or its severity. This occurs when an injured person’s diagnosis seems out of line based on the accident impact, or the medical bills are excessive. Insurance companies often question soft tissue injuries and whiplash because they’re subjective and difficult to confirm. The suspicion increases when injuries fail to respond to traditional treatments and the doctor decides that they’re permanent. Permanency allows an injured person to sue for damages not covered by PIP.
Insurance companies may consider denying a claim when an activities check, social media investigation or video surveillance turns up what they believe is evidence that your injuries aren’t genuine or as severe as you claim. They may reject your claim if a Commercial Index Bureau data search shows a history of similar claims.
If you failed to disclose prior accidents or injuries during the initial investigation, a liability carrier that uncovers them will use the information against you. They’ll deny your claim or try to diminish the value of your injury. They might also use it to portray you as an untrustworthy witness should your case go to trial.
What can you do?
- Rely on your physicians and their medical expertise to prove your injury. Unless the liability insurance company has expert information that supports its injury dispute, it will have to negotiate a settlement or defend its position in court.
- If you have prior injuries, acknowledge them and the role that they play in your current disabilities. You still have a legal right to receive damages when a current accident aggravates a previous condition.
The Insurance Company Suspects Fraud
When an insurance company suspects you of fraud, it can both insult and frustrate you. Claim investigators are responsible for identifying suspicious claims. They see every claim as potentially fraudulent until they decide otherwise. They look at every injured claimant’s economic situation, income, injuries, and accident circumstances. If they find a combination of circumstances that might indicate fraud, they might deny your claim.
A 2017 research study by the Insurance Information Institute found that insurance companies paid out an average of 30 million dollars in fraudulent property and casualty claims each year. That’s approximately 10 percent of the claim dollars paid out. It’s a big number that has insurance companies always on the lookout for signs of fraud.
What can you do?
- You can present your case and wait for the insurance company to resolve its suspicions. Unfortunately, when an injured person pushes too hard to have his or her claim resolved quickly, it’s often considered a sign of fraud.
- You can find an attorney who is willing to intervene on your behalf.
Call Sibley Dolman Accident Injury Lawyers to Solve Your Insurance Claim Problems
An insurance company might deny your injury claim for many reasons. The issues are often too complicated to handle on your own. At Sibley Dolman Accident Injury Lawyers, we have the experience to address your claim problems and resolve your case.
Our attorneys have used our firm’s resources to construct winning strategies. We have worked diligently to overcome insurance company denials and recover damages for our injured clients. We welcome the opportunity to determine if we can help you.
If you need assistance with any type of insurance claim don’t hesitate to speak with us at one of our nearest locations. with the current coronavirus pandemic give us a call or find more information about your claim online. At Sibley Dolman Accident Injury Lawyers can assist with car accident claims to Covid-19 business interruption insurance claims.
We have offices in Aventura, Boca Raton, Doral, Fort Lauderdale, and North Miami Beach. Call Sibley Dolman Accident Injury Lawyers at 833-552-7274 (833-55-CRASH) or complete our online contact form. We’ll schedule a complimentary consultation to discuss your case.
Sibley Dolman Accident Injury Lawyers, LLP
1820 NE 163rd St 306
North Miami Beach, FL, 33162