Challenging Insurance Claim Denials: Steps to Advocate for Fair Coverage
Dealing with a denied claim can be infuriating and scary, especially when you know that the loss or damage you’re experiencing was covered by your policy. It can be a distressing feeling, but you are a policyholder, and having claims denied is all part of a legitimate process when seeking equitable coverage.
Below, we will walk you through what you can do to challenge your insurers to cover a claim that they have denied. The process of challenging your insurers to cover a claim will depend on you and your organisation’s individual policy, as well as the support of a Broker, and so on. However, generally speaking, there are some steps you can take to assert your rights and put you in a position for a positive outcome. The following are the steps you should take when trying to effectively challenge your insurers.
1. Help yourself by educating yourself: Reading and understanding your policy is very important.
First steps to challenging your insurers should be to help yourself by understanding your policy and the contractual agreement you both signed. Knowing that you have a right to challenge your insurers for coverage of your claim is important.
Check Your Policy: Review your policy terms and conditions prior to challenging the claim denial.
Read the specific policy language pertaining to the denied claim and use that as a basis for your argument.
Second, get clarity on the Denial Reason: What exactly is the reason your insurer cited for the denial?
Maybe there’s an exclusion in the policy, maybe there is some missing documentation, or perhaps they misinterpreted the circumstances. Armed with this knowledge, you have the best chance to correct the problem.
Evidence: Assemble your evidence to make your case.
Gather all the documentation and supporting material related to your claim – photos, receipts, medical files, statements, proof of police reports, etc.
Get in touch: Contact your insurance company immediately to dispute the denial.
Perhaps additional evidence can be presented. Keep a record of all conversations and correspondence.
2. Request a Review: If you don’t get a satisfactory response after your initial communication, formally request a review of the denial and include the evidence.
Express why you believe you were denied.
Get a second opinion: If the company still doesn’t help you or denies the claim after you send it in, consult an attorney or your state’s insurance department.
They might be able to advise you on your rights and advocate for you as well.
Lodge an Appeal: If the company continues to deny the claim, you can appeal the determination.
Lodging an appeal involves following the administrative procedure set forth in your policy and submitting additional information or arguments to further your claim.
3. If Necessary, Consider an Appeal: If the appeal is denied, consider escalating the disagreement to a tiered management review or other external dispute-resolution mechanisms that your state may make available to resolve the issue.
But you can take some steps to feel more prepared for that process; you can even put yourself in control, if you know your policy and prepare. Step one: review your policy. It’s a simple suggestion, but reviewing your policy can help provide you with the specific conditions for coverage. You should also be on the lookout for language that can help you challenge your claim.
Often, insurance companies use ‘weasel words’ (so-called for their slippery meaning) to attempt to limit or deny coverage, making it seems like you need to prove something that you’re not. If you look at the actual language of the policy, you’ll understand what you need to prove.
For instance, a policy may state that your records and treatments up to your claim will easily be able to demonstrate coverage but it can also state that not only must you have proof of all claims, but that your records must ‘directly establish’ the existence of the medical condition you’re claiming insurance for. Some writers have coined these types of clauses gammons and stoppers that insurers use to minimise payouts.
So those are clauses that you have control over and can understand. Other clauses are intentional ambiguities, so that there’s wiggle room for whether or not you receive coverage. An injustice of this is that an insurance company can hire excellent crafting lawyers to write these ambidextrous policies, while you as the consumer don’t have access to legal advice during the time you’re buying the policy. Another step is to collect and record evidence while heading toward the point of claim. Take steps before a treatment.
