How to dispute an insurance claim denial

How to dispute an insurance claim denial

Every time you go to a new doctor, you do the same thing: Fill out long forms with all your insurance information, then give your insurance card to the receptionist. So what happens next in the insurance process? How does a claim go through once the card is in the hands of the doctor’s office?

Let’s start with a simple definition. A health insurance claim is a bill for health care services that your health care provider turns in to the insurance company for payment. With many plans, when you go to the doctor for a routine checkup and your bill is $100, you pay a co-pay or coinsurance of $25 and your doctor bills your insurance carrier for the remaining $75.

Your insurance claim actually begins before you even make an appointment. Your insurance carrier is responsible only for paying benefits that are covered under your policy, so you should do some research to avoid being shocked when you settle up with your doctor or pharmacist. Don’t hesitate to ask your insurance representative to clarify anything you don’t understand. Read your policy thoroughly so you know what’s covered. This is especially important when something comes up, like a diagnosis that requires treatment not covered in your policy.

After you’ve paid, your doctor sends your bill to an insurance claims processing center. The processing center gathers all relevant information from your doctor — the patient information sheet, intake forms and the proper services documentation. These are compared to the insurer’s explanation of benefits to see if the policy covers the services. If it does, your insurance carrier will submit payment for the remaining balance. If not, you are responsible for whatever balance is left after your co-pay.

That sounds easy enough, doesn’t it? Most claims processes are smooth, but you may encounter some bumps in the road — the dreaded denied claims. We’ll find out what to do about those in the next section.

What if you disagree with your home insurance claim’s outcome?

How to dispute an insurance claim denial

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Lorraine Roberte is an insurance writer for The Balance. As a personal finance writer, her expertise includes money management and insurance-related topics. She has written hundreds of reviews of insurance products.

You have homeowners insurance to cover damage to your home and its contents. So, when an unforeseen event happens and you have to file an insurance claim, you expect everything to be covered—especially since filing a home insurance claim often involves multiple steps.

Unfortunately, full payment from the insurance company doesn’t always come through; the insurer can deny your claim for many different reasons. Even if your claim is approved, the settlement amount may be less than you expected. Both of these situations can add to your stress and frustration levels.

If you’re having trouble settling your claim, what can you do? Learn what steps you can take to dispute the decision and try for a different outcome.

Review Your Home Insurance Policy

If your home insurance company denied your claim or approved it for an amount lower than you expected, review your policy carefully. During this review, verify that your existing policy covers your claim. If it does, note how much money you’re entitled to under your coverage limits.

Standard home insurance policies don’t cover everything. For example, damage due to floods and earthquakes is typically not covered. If you are at risk for these perils, talk to your insurance company about purchasing an additional policy to protect you.

If your claim was denied for reasons made clear in your policy, the cost for repairs or replacement is probably your responsibility. However, if your insurer made a mistake in either denying your claim or approving it for a lowball amount, you have a few different avenues for action.

Ask for Clarification

After you’ve reviewed your policy, ask your agent or insurance representative for clarification. It’s likely you’ll want to level up and speak to the claims manager directly. Why, specifically, was your claim denied, or how did the insurer arrive at the dollar amount it approved?

If the agent or representative uses language that confuses you, ask for further clarification until you understand the reasoning behind the decision that was made. If you don’t, it may be time to take another approach. If your agent can’t address your concerns, ask if the insurance company can send out a different adjuster for a second opinion.

Clear communication is essential during this stage. You want to have a complete understanding of the decision before accepting it or deciding to pursue your dispute further.

Appeal the Decision

If your insurer denies your claim, you can appeal that decision. The insurer may have a standard appeal form you can fill out, and you’ll usually need to submit it within a year or two of the date of loss. Check with your insurer about the appeal window if you’re unsure how long you have and ask about next steps.

Once you know how the process works, gather all the evidence and documentation you can to make your case. Some of the information you’ll want to gather includes:

  • The incident details (dates, damage, what you did beforehand to prevent the damage).
  • Witness statements about the incident.
  • Proof that you did what you could to prevent the incident from happening.

Submit your appeal form and the corresponding paperwork that supports your case. Your appeal should trigger a review of your denial.

A well-organized appeal can increase the chances that the insurer will do more than just a basic review of your appeal.

In the weeks and months that follow, check in with your insurer to see how your appeal is advancing through the process.

Contact Your State Department of Insurance

During the appeals process, or if you haven’t made any headway with your insurance company, reach out to your state’s department of insurance for advice, free resources, and next steps. Insurance departments typically have a number you can call for help and explanations about the basics of homeowners insurance in their state. Plus, some states might investigate your claim and/or offer free mediation services to assist you in settling without involving a lawyer.

Your state’s insurance department is led by an insurance commissioner who is a public official. In addition to providing information about policies and insurers, the commissioner’s office can investigate problems and ensure that claim decisions follow the law.

Consult a Lawyer

To assist in negotiations, especially for high-value claims, consider consulting an attorney. If you go this route, make sure you select one who specializes in home insurance claims. This way, you have the best legal representation possible. Many firms offer free consultations to review your claim and decide if you have a case worth pursuing.

If you’re considering hiring an attorney, do so before you’ve reached any binding settlement offer, such as one made via the appraisal clause in your insurance policy.

Get an Independent Appraisal

If your claim wasn’t denied, but you and your insurer disagree on the amount of the damages or repair costs, you can get an independent appraisal from an appraiser or public insurance adjuster.

Your insurance policy should clearly state the process for proceeding, under the “Appraisal” section in the policy. Often, you’ll need to submit a request in writing. Then, you and your insurance company each select a qualified appraiser. Depending on your policy, the appraisers may work to come to an accord on their own. If they can’t or if your policy specifies that they do so initially, they’ll select an impartial umpire, or mediator, who will help to determine your claim’s valuation. If at least two of the three parties agree, it sets the amount of your loss, which is binding.

You are responsible for the cost of this appraisal and split the cost of the umpire with the insurance company. It’s worth it to research the price before you begin, as public-adjuster service fees can cost as much as 20% of your settlement’s total value.

No matter which state you live in, include supporting documents to verify your complaint, so make sure you keep good records throughout the process.

File a Complaint

If you feel your insurance company has mishandled your claim, consider filing a complaint with your state insurance department. Since each state has its own process for filing a complaint, begin by researching your location’s requirements.

The Bottom Line

When you’re disputing a home insurance claim denial or low settlement offer, it’s essential to understand the terms of your coverage and the reasons why the insurer denied your claim. If you believe the company should have approved it, you should utilize your state insurance commissioner’s free resources, and may want to work with a third-party appraiser, and/or a lawyer to reach a satisfactory agreement.

When your property is damaged or destroyed, it can feel as though your safe place, your home, is no longer safe. You may feel angry, upset, helpless, and overwhelmed. And when you file a claim against your homeowners insurance policy and your insurance company denies your claim or offers significantly less than the cost of the repairs or replacement, it can feel like they’re working against you rather than supporting you.

Good news: you’re still in control. You do not have to accept the insurance company’s response. As a policyholder, you have the right to dispute your insurer over a denial or underpayment of your insurance claim.

Save time and aggravation by following these simple steps:

Step 1: Know Why Your Insurance Claim Was Denied or Underpaid
If you don’t understand why your claim was denied or underpaid, talk to your insurance adjuster or representative directly. If the denial cites an exclusion or uses specific language that you don’t understand, ask the person to point out the section in your policy and explain in clear language what it means.

The same holds true for underpayment. Sometimes an adjuster will undervalue a replacement or repair. In other cases, the dispute is over the extent of the damage. Once you understand the reason for the underpayment you can then submit additional estimates or request an independent appraisal.
As mentioned in, “9 Insider Tips for Filing an Insurance Claim After a Disaster”, document all communications. If there is no record, it didn’t happen. Keep a log of every conversation you have with your insurance representative, desk adjuster, field adjuster, etc.; include dates, times of day, names and what was said.

Step 2: Appeal Your Denied or Underpaid Settlement
You have the right to appeal an insurance claim denial or settlement offer. And, your insurance company has a responsibility to pay – after your deductible has been met – an amount that will allow you to restore your home to its original condition.

Be sure to submit your detailed letter along with pictures and any additional estimates and/or documentation within the timeline specified.

Step 3: When to Cash Insurance Checks
Clients worry that if they cash any insurance checks they are agreeing to settle for that amount. As long as you did not sign a release, you are free to cash the check, even when there is language on the back of the check warning you that cashing the check acts as a full and final settlement of the claim.

Step 4: Contact an Insurance Attorney
An insurance attorney can help you with all aspects of your appeal. And, if need be, The Desir Insurance Law Firm can even file a lawsuit to get you the settlement you deserve.

Florida law allows for the recovery of attorney’s fees and costs from your insurance company, if you prevail in a lawsuit. At Desir Law Firm, even if we do not prevail, you will not owe money to an attorney since our cases are taken on a contingency basis. It is truly a win-win situation to hire an insurance attorney to dispute a partial or complete insurance denial or partial payments.

The information provided here is intended for informational purposes and should not be considered legal advice.

Insurance companies play an active role in our everyday lives. If you own a home or a car, chances are, you have an insurance company. Insurance companies have the right to refuse approval of your insurance claim; however, they have to provide proof for choosing to deny. If your insurance company has denied your claim, you have the option to sue the insurance company.

How to Sue an Insurance Company: First Things First

Before you research lawyers who sue insurance companies, you first need to obtain some preliminary information and exhaust all possible resources.

First, find a copy of the policy agreement you signed with your insurance company when the policy was written. Familiarize yourself with the policy to justify why the insurance company should approve your claim rather than deny.

How to dispute an insurance claim denial

Take pictures of any property or damage associated with the incident. Keep receipts of any purchases associated with the incident. These purchases can be recorded and pursued for reimbursement.

If the insurance company has denied your claim, you need to request a written explanation for the denial. A written request of the denial can be given to your lawyer for review. The denial can be compared with the policy to see if the denial is valid.

Finally, you should attempt to file an appeal with additional documentation with the insurance company. The appeal process will allow the appeal and supporting documentation to be reviewed. This also shows the insurance company, as well as the court, that all avenues have been exhausted to try to reach a resolution.

If the claim is still denied after the appeal has been reviewed, you should gather all information and consult a lawyer to discuss your options for how to sue the insurance company.

How Can I Sue my Insurance Company?

Once all resources have been exhausted, you have the option to hire a lawyer to sue your insurance company.

You will need to find a lawyer in your area who is familiar with civil law. A lawyer who specializes in laws regarding insurance claims will be the most beneficial. This lawyer will know the questions to ask, the documents to request, and the evidence to present.

How to dispute an insurance claim denial

Your lawyer will need a copy of the insurance policy, denial letter, and your appeal information. Your lawyer will review the information and prepare to file the lawsuit.

When the lawsuit is filed, your insurance company will respond, as well as hire a lawyer to represent them. Once the insurance company responds to the lawsuit, each party will exchange information about the evidence that will be presented at the hearing. Each side will be able to review the counterparty’s evidence.

Once the evidence has been reviewed, a settlement may be proposed. Depending on the amount you are requesting, the settlement may be too low. Based on the evidence in your case, your lawyer may advise you to accept or deny the settlement.

If a settlement is not reached, the lawsuit will go to court. Each side will present their evidence, which can include depositions and witness testimony. The judge will make the final ruling on the amount to be awarded, if any.

What Type of Expenses and Damages Can I Sue My Insurance Company?

How to dispute an insurance claim denial

If your incident has resulted in medical bills, lost wages due to missed time at work, property damage, attorney fees, and emotional distress, keep a record of these expenditures. This documentation will help your lawyer prepare the lawsuit to go to trial.

I have been Offered a Settlement – Should I Accept?

A settlement offers many benefits to all parties involved.

First, a settlement keeps the lawsuit from having to go to court. Settling out-of-court will allow for a quicker resolution.

Second, settling out-of-court allows you to know exactly what settlement amount you will receive, whereas going to trial may result in a judgment award lower than requested.

Finally, settling out-of-court will decrease the amount spent on lawyers, as going to court will cause you to continue paying for representation.

My Insurer has Denied my Claim – Should I Look for a New Insurer?

How to dispute an insurance claim denial

Depending on the reason for the denial, you may consider finding a new insurance company for your home or automobile coverage. Your insurance company may have a good reason for denying your claim. If you have had a good experience with your insurance company, other than the recent denial of your claim, you may consider continuing to make use of your insurer. However, if you have had issues with your insurer prior to the denial of your claim, you may consider finding a new insurance company.

Conclusion

If you have filed a claim with your insurance company and your claim has been denied, you have the option to sue your insurance company.

First, you should file an appeal with the insurance company for your claim to be reviewed. The review of your claim may mean another representative within the company looks over the claim and decides to approve it.

If your appeal is still denied after your appeal, you should take all information pertaining to your claim and seek an attorney who practices civil law. A lawyer familiar with the civil arena who specializes in insurance claims will review your information and begin building your case.

During this time, your lawyer will prepare the lawsuit to file to the court. Once the insurance company has been notified of the lawsuit, they will respond to your lawyer. At this point, each party will exchange information to determine the evidence that will be presented during the trial. Your lawyer will take depositions and prepare witness testimonies.

During the preparation of your case, a settlement offer may be presented. This settlement may be lower than the amount requested in the lawsuit. Your lawyer will advise you whether you should accept the offer or refuse.

If you accept the settlement offer, the case will be resolved without going to trial. Alternatively, you can choose to refuse the settlement and continue to take the case to court.

If your case goes to court, both sides will present their evidence and witness testimonies. A judge will hear both sides and make a ruling based on the evidence. The judge may rule in favor of either side.

If you need assistance, you can also chat now with a Laws101.com attorney, where you’ll be instantly connected to a lawyer who can give you legal guidance on your specific case or question.

Common Reasons Claims Are Denied and How to Write a Claims Appeal Letter

How to dispute an insurance claim denial

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Sometimes you must fight for your rights when it comes to health insurance. Mistakes can cause valid claims to be denied. To launch a winning appeal, you need the facts.

First, learn why the claim was denied. It could be an error in how the claim was entered into the insurance system. Maybe a claims processing agent made e a mistake. There could be information missing. Do your research.

All health insurers have ways to appeal unpaid claims. If you know how to fight a denied health insurance claim, it may get covered after going through that process.

Key Takeaways

  • If you don’t know why your claim was denied, you can’t mount a strong appeal.
  • An effective appeal letter contains a clear opening statement, explanation of your medical condition, and supporting data from your doctor.
  • If your claim was denied because it clearly did not fall within what your policy covers, it may not be worth the effort of writing an appeal.

Denied Claims vs. Rejected Claims

A health insurance claim denial is when an insurance company does not approve payment for a specific claim. In this case, the health insurer decides not to pay for a procedure, test, or prescription.

A claim rejection, on the other hand, can be easy to correct. A rejected claim is one that is not processed because incorrect information is submitted with the health insurance claim form. Rejected claims do not have to be appealed. Simply correct the error. Resubmit the right information and your insurance company will begin to process the claim.

5 Reasons a Health Insurance Claim Could Be Denied

Knowing why your health insurance claim was denied is key. It lets you know if you can appeal the decision. If your appeal succeeds, the company must pay for the claim even though it was denied at first.

Here are five common reasons health insurance claims are denied:

  1. There may be incomplete or missing information in the submitted claim documents or there could be medical billing errors.
  2. Your health insurance plan may not cover what you are claiming, or the procedure may not be deemed medically necessary.
  3. You may have maxed out the coverage limits in your plan.
  4. The drug or therapy is off-formulary and not part of your health plan.
  5. You may have used out-of-network services or used your health insurance out of state when your health plan requires “in-network” providers.

How to Fight a Health Insurance Claim Decision

You will receive a denial notice if your health insurance claim is denied. The notice should tell you how long you have to appeal the decision. It is crucial you don’t miss your deadline.

Before you begin the appeal, find out why your claim was denied. Appeals won’t always make sense if your plan clearly states the service you need is not covered, you were out of network, or you have maxed out the coverage limit for the year.

If you’re not sure, review your health insurer’s website. You can also call to better understand your health insurance policy coverage and the reason for your claim denial.

Write an Appeal Letter to Fight a Claim Denial

Writing an appeal letter for your denied health insurance claim is a matter of sharing the proper information to have your case looked at as soon as possible.

If you request an appeal but can’t share why your claim was denied, the insurance company may find it hard to review your appeal. Talk with someone in the claims department to make sure you understand the reason for the denial and how the appeal process works.

To avoid delays, follow the appeal procedure exactly as outlined. Double-check it before you send it. You want the information they request to go to the right department or person.

What Your Appeal Letter Should Include

A health insurance claim denial can frustrate you to tears. Keep the emotion out of it. A simple appeal letter that gets straight to the point is the best approach. Your appeal letter should be “matter of fact” in tone. Include any information your insurance company tells you is needed.

Your appeal letter should include these things:

Opening Statement

State why you are writing and what service, treatment, or therapy was denied. Include the reason for the denial. Your intro can state: “I am writing about Claim Number 123456ABC. I received a letter denying my claim for XYZ services, for this reason: ______________. I would like to appeal this decision.”

Explain Your Health Condition

Outline your medical history and health problems. Explain why you need the treatment and why you believe it is medically necessary. List any treatments you already tried. Explain why you believe the current treatment may be a solution.

Get a Doctor to Support You

You need a doctor’s note. Ask them to support you with information that verifies your statements about your health and the treatment. If the treatment is new, provide documentation from recognized institutions such as hospitals and medical schools that show it as part of a recognized treatment plan.

Send your appeal on time by certified mail. You want to have proof you submitted your request within the time limit. If appeals are accepted only online, keep records of all emails showing time sent,

When looking to appeal a health insurance claim denial, the key is to understand your coverage and why your claim was denied.

Health Insurance Claim Denied? How to Appeal the Denial

In times of illness or injury, the last thing you need to worry about is your health insurance coverage. If a health claim has been denied, here are some tips to help you understand what you can do.

TOP CONSIDERATIONS

Why a claim gets denied: In some cases, a simple error could be why your claim was denied. Your provider’s billing staff may have entered an incorrect code, or your claim may have accidentally been sent to the wrong insurance company. This type of error can usually be cleared up quickly with a single phone call. But sometimes the reason can be more complex and require additional steps to get resolved.

The appeals process: Your policy should indicate how to appeal a denial. There are typically two levels of appeal: a first-level internal appeal administered by the insurance company and then a second-level external review administered by an independent third-party. Your state insurance department will be able to explain the appeals process in more detail.

Timelines for appeals: Generally, your insurance provider must make a decision regarding your internal appeal within the following timelines after receiving your request:

72 hours if you’re appealing the denial of a claim for urgent care.

30 days for treatment that you haven’t received yet.

60 days for treatment you have already received.

THINGS YOU SHOULD KNOW

Contact your insurance company: If you receive notice that your claim was denied, call your insurance company. You should find contact information on the back of your insurance card and the denial notice. Before you call:

Make a list. Have handy all the questions you have about your claim’s denial as well as the details of your treatment.

Gather all important documents. This includes your policy, the Summary of Benefits Coverage (SBC), and your denial letter.

Keep notes of all conversations you have with company representatives. Make sure to note who you speak with, as well as the date and time you spoke. Ask for the person’s phone extension so you can contact them directly the next time you need to call.

If your insurer continues to deny your claim, be persistent: The usual procedure for appealing a claim denial involves submitting a letter to your insurance company. Make sure to:

Give specific reasons why your claim should be paid under your policy.

Be as detailed as possible when composing your letter.

Explain why your procedure or medication is necessary.

Include evidence that supports your claim. This could include medical records like x-rays, lab results, or a letter from your physician that explains why your treatment is medically necessary.

Ask to expedite the appeal if you or your doctor feels that the denial of your claim could be life-threatening.

Keep copies of everything you send to the insurance company for your records.

Contact your state Department of Insurance if you feel your insurer is not cooperating with the appeals process.

TOP THREE THINGS TO REMEMBER

If a claim is denied, don’t panic. It could be a simple error that is easily fixed with a phone call.

When contacting your insurance provider about the denial, make a list of questions and gather all important documents beforehand. Keep detailed notes including the name, title and phone number of the person you spoke with.

When appealing the claim be persistent. Send your insurance company a note, being as specific as possible about why your claim should be paid and including as much evidence as you can to support your argument.

Health Insurance Claim Denied? How to Appeal the Denial

In times of illness or injury, the last thing you need to worry about is your health insurance coverage. If a health claim has been denied, here are some tips to help you understand what you can do.

TOP CONSIDERATIONS

Why a claim gets denied: In some cases, a simple error could be why your claim was denied. Your provider’s billing staff may have entered an incorrect code, or your claim may have accidentally been sent to the wrong insurance company. This type of error can usually be cleared up quickly with a single phone call. But sometimes the reason can be more complex and require additional steps to get resolved.

The appeals process: Your policy should indicate how to appeal a denial. There are typically two levels of appeal: a first-level internal appeal administered by the insurance company and then a second-level external review administered by an independent third-party. Your state insurance department will be able to explain the appeals process in more detail.

Timelines for appeals: Generally, your insurance provider must make a decision regarding your internal appeal within the following timelines after receiving your request:

72 hours if you’re appealing the denial of a claim for urgent care.

30 days for treatment that you haven’t received yet.

60 days for treatment you have already received.

THINGS YOU SHOULD KNOW

Contact your insurance company: If you receive notice that your claim was denied, call your insurance company. You should find contact information on the back of your insurance card and the denial notice. Before you call:

Make a list. Have handy all the questions you have about your claim’s denial as well as the details of your treatment.

Gather all important documents. This includes your policy, the Summary of Benefits Coverage (SBC), and your denial letter.

Keep notes of all conversations you have with company representatives. Make sure to note who you speak with, as well as the date and time you spoke. Ask for the person’s phone extension so you can contact them directly the next time you need to call.

If your insurer continues to deny your claim, be persistent: The usual procedure for appealing a claim denial involves submitting a letter to your insurance company. Make sure to:

Give specific reasons why your claim should be paid under your policy.

Be as detailed as possible when composing your letter.

Explain why your procedure or medication is necessary.

Include evidence that supports your claim. This could include medical records like x-rays, lab results, or a letter from your physician that explains why your treatment is medically necessary.

Ask to expedite the appeal if you or your doctor feels that the denial of your claim could be life-threatening.

Keep copies of everything you send to the insurance company for your records.

Contact your state Department of Insurance if you feel your insurer is not cooperating with the appeals process.

TOP THREE THINGS TO REMEMBER

If a claim is denied, don’t panic. It could be a simple error that is easily fixed with a phone call.

When contacting your insurance provider about the denial, make a list of questions and gather all important documents beforehand. Keep detailed notes including the name, title and phone number of the person you spoke with.

When appealing the claim be persistent. Send your insurance company a note, being as specific as possible about why your claim should be paid and including as much evidence as you can to support your argument.

You most likely bought homeowners insurance to protect your family’s assets. You sought peace of mind through the promise that in the event of a tragedy, your insurance company would reimburse you for losses. But when a legitimate claim is denied, your peace of mind can quickly turn to stress and confusion.

It’s not easy to understand why insurance companies deny claims, but it happens more often than you may think. Often, it’s a simple lack of paperwork that turns into an argument with your insurer over how much you are owed under your policy. Your insurer owes you a duty of good faith, and if insurance company employees treat you unfairly, an insurance bad faith attorney in South Dakota can help you take action.

Review the Reasons for Denial

Your insurer should have sent you a detailed explanation of why your claim was denied. Be sure to read the letter, and read the language in your policy if you have a copy.

Contact Your Insurer

Though you may not want to contact your insurer, write them a letter or email to ask for more information about why you were denied. If the insurer insists on calling you, keep notes of these conversations, but respond in writing. Try to be polite, since the person answering the phone isn’t the one who denied your claim, and you probably are being recorded.

Appeal the Denial

Your insurer should have given you a route to appeal denial your claim. Follow this procedure closely, because you can have an appeal denied on a technicality. Prepare your appeal with care. At this point, you may want to ask a lawyer to review what you’ve written to make sure you’ve included all the information the company wants to see.

Hire an Independent Adjuster

You may have the option to hire your own adjuster to evaluate your claim. This can bolster your argument that your request for assistance was unfairly denied.

Speak With a Lawyer

When you are intimidated by the process and already under stress, it can be difficult to advocate for yourself, even when a substantial claim is at stake. A lawyer can help you.

Since insurance lawyers know how the system works, they can help you prepare an appeal that is less likely to be denied, and even speak to the company on your behalf. You can hire an attorney at any stage of the process.

If you want home insurance claim advice or more information about how to fight a homeowners’ insurance claim denial, contact Turbak Law at (866) 231-0914 for a consultation.