What Are the Top Reasons for Insurance Denials?

You have a 50/50 chance of an insurance company denying your claim. While you can do things to increase your odds, such as collecting evidence from your accident and fully completing all required paperwork, the insurance company can make it difficult to achieve a fair settlement. Insurance companies have many reasons for denying claims – not all of them legal or valid. If an insurance company denies your claim to benefits after an accident in California, you may have options for recourse.

Failure to Receive Medical Treatment

If you do not have medical records documenting the injury you are putting on your insurance claim, the insurance company will most likely deny benefits. The insurance company needs proof that you are in fact injured, and that your injuries arose the way you say they did. Always see a doctor immediately after an accident to document your injuries. Request copies of your relevant medical records to submit to the insurance company. Submit records on your own rather than signing a blanket medical authorization form from the insurance company. The insurer may use this form to access your full records and look for reasons to deny your claim.

Your Injuries Are From a Pre-Existing Condition

A common reason for an insurance company to ask for medical authorization is to look for pre-existing injuries. If you have a pre-existing injury that your current injury affects, or vice versa, the insurance company may use your prior condition as a reason to deny your claim. This may or may not be a valid reason depending on the situation. If your new injury has made your pre-existing condition worse, or your condition has made the symptoms of your new injury worse, you could still be eligible for insurance benefits.

Filing a Claim After the Deadline

You have a responsibility to file an insurance claim as soon as possible after an accident in California. Waiting too long to report the accident and injury is a reason the insurance company might give for denying your claim. Most insurance companies have tight deadlines by which all claimants must file their claims. Typically, you need to report an accident to an insurance company within 24 to 72 hours of the accident.

Your Employer Is Disputing the Claim

If you are filing a workers’ compensation insurance claim in California, you may run into problems if your employer disputes liability. If the report your employer files about the accident states that he or she believes something else caused your injuries, such as horseplay or intoxication, the workers’ comp insurance company may deny your claim to benefits. You may be able to fight back in a liability dispute with help from a lawyer.

Bad Faith Insurance Denials

If the insurance company has a legal reason to deny your claim, you may be able to request an internal review of your case to change the insurance company’s answer. A different representative within the insurance company will take another look at your claim, including any additional paperwork or evidence you have submitted since receiving the denial letter. If the internal review does not reverse the decision, you can also go to the California Department of Insurance to request an external review.

If you believe an insurance company has denied your claim in bad faith after an accident in California, contact a personal injury attorney for assistance. You may be able to go up against the insurance company in a bad-faith insurance lawsuit. Bad faith means the insurance company denied your claim wrongfully or without a valid reason. This can happen when an insurance company wishes to save money by denying and delaying as many claims as possible. If you believe the insurance company handled your claim dishonestly, unfairly or in bad faith, speak to an attorney about filing a lawsuit against the insurer.