Let’s say you’re injured in a car accident. It’s something that happens in the U.S. thousands of times per day. The unfortunate part – aside from being injured – is that the moment the accident happens, a tab begins to run. The ambulance ride, the medication, the long stays in the hospital, surgery, specialists; if any or all of these things are necessary, you may be left with a very large medical bill by the end of your treatment. It’s a good thing you have insurance, right?
You may be surprised to learn that insurance companies rarely have your best interests in mind. In fact, their interests lie with stock holders and their goals are to increase profits and limit claim payouts – they even categorize claim payouts as ‘losses’. The ‘loss ratio’ is an important accounting figure in the insurance industry, which compares the amount of claims paid out vs. the amount of premiums collected.
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WHY WOULD MY INSURANCE COMPANY DENY MY CLAIM?
By nature of being in the insurance industry, insurance companies receive thousands and thousands of claims each year. In fact, here are the auto insurance claim rates in the U.S. per 500 vehicles – considering that there are nearly 200 million insured in the U.S., that is a lot of claims.
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In order to maximize their profits, they deny as many as they possibly can. There are a multitude of reasons an insurance company can use to deny an insurance claim, and many of them can seem extremely underhanded if not unethical.
- Insurance companies will use even the smallest clerical error as a reason for denial. If you for some reason have the incorrect birth date on your form, or if your doctor filed your injuries incorrectly, they can deny your claim.
- The insurance company will attempt to determine if there was any negligence on your part that could have contributed to your injury, even if in a very small way. Some states use contributory negligence, which means if you are even partially at fault, you won’t get any compensation. However, most states use comparative negligence, which means that if you’re 50 percent at fault, you’ll receive 50 percent compensation of total damages.
- If you see a doctor who is not within the provided network, especially if you have a health maintenance organization (HMO) as your insurer, they can deny your claim.
- Insurance companies could give you the silent treatment by not answering or returning phone calls, because they want you to eventually give up on the claim. The best way to combat this is to have your lawyer start making them for you. They will answer then.
- Be extremely careful how you phrase something when talking to insurance. Even if you respond with, “Fine,” when asked how you’re doing, they can use that to deny your claim. Phrasing is incredibly important in the insurance industry. An example that is a gross technicality at best and extortion at the worst, one company claimed that the driver at fault in a Kansas City car accident had caused it intentionally, thereby deeming it not an “accident.” It should be noted that laws have been put into place that prevent insurance companies from doing something similar.
- There are many technicalities under which your claim can be denied. One anecdote says that if a tree falls on your house you are covered, but if a storm rolls in three hours later and your house becomes flooded, you aren’t covered for that. A phrase that will bear repeating, be sure to read your policy. That is easier said than done, of course.
The world of insurance is so confusing and murky to most policyholders that it’s impossible to decipher for what they are actually covered. And that’s the way insurance companies want it, because the less they pay in claims the more money they make.
PREVENTING A DENIAL AND GETTING FULL COMPENSATION
When you are dependent upon the money you’d receive from a claim just to pay your bills, any delay or denial can be disastrous. Fortunately, there are several ways you can avoid a denial of your claim:
- Always try to stay on top of payments, no matter what. Suppose you are injured in an accident. The only thing you’re thinking about is how you’re going to get better, but what if the injury happens to coincide with an upcoming due date on your insurance premiums?
- Don’t conceal any information, as it could backfire horrendously if you actually need to file a claim. If they find out, the insurance company could claim it as a pre-existing condition and deny your claim.
- Be as detailed as possible. For instance, in a car accident, describe every subtlety of the scene. Have someone take photos of injuries, return to the scene if you can and document anything that could have caused the accident; you should even contact witnesses. Any evidence you can gather will help make your case irrefutable.
- Verify every minute detail in your policy is correct. You may get even the time of your injury right down to the second on your claim, but if any information on your policy turns out to be incorrect, insurance can deny your claim.
When accounting for damages in personal injury, emotional ones can be just as important to note as physical ones. While subjective, emotional damages such as distress or loss of consortium are quantifiable and can be included. Overall, being upfront and including every detail of your medical history on your policy will make the process of filing a claim much easier, and significantly decrease the chances of a denial. There are ways you can affect how much you’re compensated as well.
You will be telling your story to numerous people after an accident in which you sustain an injury. What you do immediately after an injury accident is very important, especially when making a statement to others involved. Even though emotions may be high during this time, you have to be very careful about what you say, as many things can be interpreted as an admission of guilt. How quickly you sought medical attention matters a great deal as well, because if it took you a while to seek this, the insurance company can say that whatever injury you sustained must not have been that bad and therefore won’t award you full compensation.
As previously stated, not only do you have to watch what you say to others involved in your accident and/or injury, but you have to be wary what you say to the insurance adjuster as well. Even saying something which leaves room for interpretation during a simple phone conversation can be turned against you. When a serious injury occurs or you feel you are being treated unfairly, this is when it’s good to hire a lawyer.
IMPORTANCE OF AN ATTORNEY AND RIGHT TO APPEAL
There are some instances, such as a car accident with no injuries or a case involving a defective product, where a lawyer may not be necessary. However, it can oftentimes happen that there is just too much paperwork or too much confusion in an injury case, especially if said injury is serious in nature. When you’re unable to handle the claim on your own, an attorney becomes a worthwhile expense.
This is especially true the more complicated a case is. If witnesses – expert and those present at the scene – are necessary, an attorney will know the proper line of questioning and application of evidence to prove your case. If you are claiming general damages in Missouri, such as mental anguish, a court or insurance company may not accept your judgement of monetary compensation. A Kansas City personal injury lawyer can not only help you quantify these damages, but ensure that you are properly compensated.
HOW DO I APPEAL A DENIED INSURANCE CLAIM?
If your claim is denied, you have the right to appeal the denial. It’s important not to simply take a denial as the final outcome of your claim. A study found that between 30 and 59 percent of people who appeal insurance claim denials win their appeal. The problem is, most people don’t know that they can or how to appeal. Thus, it’s important to understand the appeals process and your rights contained therein.
- The insurance company must provide a written explanation for their denial anywhere between 3-30 days depending upon the type of claim filed. After receiving this notice you have to file your appeal within 180 days.
- There are many types of denials that can be appealed, including treatment deemed experimental, investigative or unnecessary, the company cancelling your coverage based on false information, and insurance deeming your injury a pre-existing condition are all grounds for an appeal.
- Keep copies of every sheet of paper related to your appeal. The Explanation of Benefits form, any correspondence with the insurance company and the appeal itself should all be kept in your personal records.
Appeals take 30-60 days to process, but in urgent situations, you can request an expedited external review even before the completion of the internal appeal. An external can also be filed if the internal appeal is denied.
- An external review must be filed within 60 days of receiving a denial of your internal appeal. A denial that involves medical judgement of any kind, as well as the revocation of your coverage are grounds for filing an external review.
- The insurance company must participate in this process, which varies state-to-state. Some don’t have specific parameters for an external review, in which case the review will be handled by the Department of Health and Human Services.
- You can have someone else, such as your doctor, file a review for you, and you can request help in filing one as well. Reviews are decided quickly, and you should expect a result no later than 60 days after filing.
Finally, a good thing to know is that you can hire an attorney at any point during the claims process, so long as it’s before you sign the release form. Having an attorney to help you navigate the figurative hurricane of paperwork, legal hoops and potential appeals process can bring peace of mind, especially when recovering from injury. Because an insurance company won’t always be on your side.