What to Do If an Insurance Company Denied Your Benefits Following an Injury

Insurance coverage offers you invaluable protection when the unexpected arises. However, insurance companies, like any other company, are in the business of making money. Insurance carriers aim to collect the most in premiums to pay out as little as possible in claims. 

There are many legitimate reasons that an insurance company could deny your claim, but in many situations, they are in the wrong. You need a denied insurance claims attorney to review your case. Contact us today for a complimentary case evaluation.

Reasons Your Insurance Claim May Be Denied

Insurance is supposed to afford us peace of mind. Among the list of insurances we carry, automobile and health insurance are policies that are dealt with frequently.

Car Accident Claims

When an automobile accident occurs, the police file a report alleging who they find responsible for the accident. California is an at-fault or “tort” state, meaning that all automobile insurance claims must be filed with the at-fault driver’s insurance company. 

However, insurance companies will only agree to pay if there is clear evidence that their policyholder is at fault. If there is any evidence that supports you may partially be at fault for the accident, the insurance company may only agree to pay 50% of your submitted claim if you and the other party agree to share responsibility for the accident. 

Never admit fault in an accident without first speaking with a reputable denied insurance claims attorney.

Health Insurance Claims

According to the United States Census Bureau, 8.9% of the population under the age of 65 do not carry health insurance. This is a segment of the population that is not covered should a medical emergency arise.

Health insurance companies are notorious for denying claims, meaning that they refuse to pay for a prescription, test, or other procedure.

Some common reasons for health insurance companies to deny claims are:

  • the procedure is not covered by your plan
  • the insurance carrier has determined the test or procedure is too expensive
  • the insurance carrier determined the treatment was medically unnecessary
  • a paperwork or coding error
  • the treatment would be administered by an out-of-network provider

With health insurance claims, the health insurer is making medical assessments based on the paperwork submitted. Often, the insurer is incorrect in their decision, and it is worthwhile for you to appeal their decision. 

Steps to Take after Your Insurance Claim is Denied

If your insurance company denied your request for medical treatment, and you believe that they are in the wrong, you can challenge the denial by filing an appeal directly with the company. This appeal can be done through the California Department of Insurance. 

On a similar note, if your health insurance company determines that the treatment you received was not medically necessary, you can request an Independent Medical Review (IMR) with the California Department of Insurance. You will need to submit all necessary paperwork supporting the treatment to the Department of Insurance. It is also crucial that the request be made within six months of the insurance company’s upholding its decision on appeal.

Can You File a Lawsuit Against an Insurance Company?

While some of these reasons may be legitimate, often the insurance company is avoiding its obligation to pay. In these circumstances, the insurance company is acting in “bad faith.” If an insurance company has denied a valid claim on an active insurance policy, then the carrier is breaching the contract. 

The California Legislature has protections for policyholders if this ever happens, allowing the policyholder to sue the insurance carrier. This forces the insurance carrier to fully investigate the claim. 

Hire an Aggressive Denied Insurance Claims Attorney

From the moment that an insurance company denies your claim, you need a knowledgeable attorney on your side. With over 35 years of experience, the attorneys at the Law Office of Scott Righthand, P.C. are a trusted legal team for the Bay Area. Contact our office today to schedule a no-obligation case evaluation.

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Date Of Posting

19 June,2022

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