Denial of Insurance Claims

The recovery process doesn’t have to end if an insurance company denies your claim. You can – and should – fight the denial with an insurance appeal. Retaining an insurance bad faith lawyer to guide you through this legal process can make it much easier for you and your family – especially if you’re trying to recover from serious injuries. Don’t look at the denial of an insurance claim as the end, but instead as an obstacle you must overcome. Learn about the appeals process in Texas with help from local personal injury lawyers.

Review Your Insurance Policy

Your insurance policy documents will give, in detail, all the information you need about the contact you have with your insurer. That’s what an insurance plan is – a contract between you, the insured, and the insurance company. Review your auto, home, or health insurance policy depending on the company that’s denying your claim. Rules under the Obama Administration require all health insurers to provide benefits and coverage summaries to policyholders.

Your policy will explain what the insurance company does and does not cover, the requirements for receiving benefits, the maximum amounts of coverage, deduction amounts, how to file a claim, and more. It will also explain how to go about the claim denial appeals process with the specific company. You can also contact the Texas Department of Insurance if you have issues regarding your policy, or your employer if you receive insurance through a company.

Understand the Reason for the Claim Denial

An insurance company cannot legally deny your claim without notifying you of the reason for the denial. The Affordable Care Act (ACA) ensures your rights to a reason for the denial, to the ability to make an appeal, and to instructions and a deadline for the appeal. The ACA also protects you from insurance company retaliation, such as the company dropping you as a client for disagreeing with a denial or making an appeal. You also have the power to ask for an external claim review process if you aren’t happy with the insurance company’s response.

Upon receiving a claim denial, read the letter the insurance company sent you as an explanation or call the company for more details. The denial may actually be a request for more information, such as further documentation of your injuries or property damage. The denial might also have stemmed from miscommunication or misinterpretation of details of the claim, such as the company thinking you missed a filing deadline when in fact you did not.

Learning why the denial occurred may enable you to remedy the situation on your own, without an official appeal. Otherwise, you can take your grievance to court. Common reasons for claim denials include that the services you’re requesting aren’t medically necessary, the services are “experimental” or “investigational,” no one has proven the effectiveness of the treatment, or that you’re ineligible for benefits based on your insurance plan.

Hire an Attorney for Help with the Appeal

Document the facts of your accident and insurance claim before beginning the appeals process. You will need copies of any written correspondence between you and the insurance company, the names of insurance agents and claims adjusters assigned to your case, and summaries of your conversations with the insurance company. To submit your appeal, you may need a letter of support from your medical provider, results of relevant medical tests, evidence of the effectiveness of a treatment, and an official Appeal Letter.

A lawyer can help you with the steps of the appeal process, from writing your letter and providing evidence to representing you during a trial in Texas. You may go through steps such as a Request for Reconsideration, a Second-Level Appeal, and an external review. If your initial appeal fails, you can pursue the issue in a court of law. Hiring a lawyer will improve your odds of a successful appeal of an insurance claim denial in Texas.