Insurance companies offer help in times of crisis, but they are unable to approve every claim they receive. They must deny some claims to discourage abuse of the insurance system as well as maintain a fair profit. Most of the time, denials are legitimate. Sometimes, however, an insurance company wrongly denies a claim, and the insured must file an appeal.
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Review your policy. Determine whether the policy terms actually allow for denial of your claim. Find out through these terms exactly why the insurance company has made their decision. Insurance companies often quote the policy in their denial letters, but double-check that they've quoted and interpreted the policy correctly. Policy wording can sometimes be ambiguous.
Write a letter of response to the insurance company as soon as they've confirmed the claim denial. Tell the company you do not agree with the denial and plan to dispute it. Also indicate your intention to file an appeal. Include basic contact information, your full policy number as it appears on your policy, the nature of the claim, the claim number, the date you made the claim, the date the claim was denied and the name of the agent who denied the claim. Address the letter to a specific customer service representative who deals with denials.
Conduct market research that shows the value of your damaged or lost property, or the procedure or service that you need. Collect sales receipts, advertisements and similar documents. Call around or e-mail professionals and ask for a written estimate on repairs, replacement, procedures and services. Hire an independent appraiser if necessary.
Ask for written statements from anyone who might carry weight with the insurance company. For example, a plastic surgeon may testify that reconstructive surgery to your jaw will improve chewing and biting, not just improve your appearance. Police officers and firemen can also help. Statements from general witnesses give further evidence, but may not be as authoritative as you need.
File the necessary paperwork for your appeal exactly as stipulated by the insurance company.
Hire a competent attorney who specialises in insurance law. Contact your state bar association and ask about insurance lawyers who may work with you on a pro bono basis if you cannot afford an attorney.
Make copies of all your documentation and give the copies to your attorney.
Consult with your attorney to build a list of cases similar to yours where benefits were paid. Identify the exact amounts paid to show what is reasonable for an insurance company to pay in your circumstances.
Have your attorney contact the insurance company and arrange for a dispute hearing or attendance at any hearings that are part of the insurance company's appeal process. During the hearing, present the insurance company representatives with your documentation. Remind them of the benefits of putting your claim through, such as the fact that they will avoid legal fees. Present your desired claim amount in writing.
Give the insurance representatives time to consider your documentation and arguments. If they still deny your claim, have your attorney file a formal lawsuit. Use your documentation to sway the judge to rule in your favour.
Tips and warnings
- Watch your language in your correspondence. Avoid words that make your needs sound cosmetic, or any that come off as accusatory.
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