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I Think My Insurance Underpaid My Claim.  What Can I Do?

If your insurance company issues a coverage decision with which you disagree, you have the right to pursue internal appeals and external reviews.  If your insurer already owes you benefits and is underpaying, you may have a claim for delayed payments or even a claim for insurance bad faith.  Your insurance law attorney will help you chart the best path for recovering the full benefits you are due.

Undervalued Claim

If your claim was undervalued in the decision rendered by your insurance company, you have the option to challenge the insurer’s decision.  They should have sent you a written notice explaining their coverage decision.  If it appears to be a clerical error, you may be able to resolve the issue with your claims adjuster.  If they have firmly decided to undervalue your claim, you can file an appeal within the insurance company challenging their coverage decision.  If they resolve your appeal and still undervalue your claim, you can seek independent review from the appropriate California state agency.

Claim Value Established but Only Partial Benefits Paid

If your claim for coverage has been accepted but the insurance company has been issuing only partial payments, then your options depend on the nature of your claim.  If you are obtaining coverage for medical care, then the underpayment is a matter for your healthcare provider to resolve with the insurance company.  The hospital or medical office will undertake its own negotiations and appeals process with the insurance company.

If your insurer owes you benefits directly, then you have several options available depending on the nature of the insurer’s conduct and the type of insurance claim, discussed below.  Talk to an insurance law attorney for advice and representation pursuing the payments you are owed.

Claim for Delayed Payments

Depending on the type of insurance claim, your insurance company may owe you specific penalties based on delays in paying your claim.  If your insurer owes you payments on a disability claim, they must pay in full on time.  For any late payments on temporary or permanent disability payments, they must pay an additional penalty of 10 percent of the value of your overdue benefits (meaning they must pay you 110% of what they owe).

If the insurance company’s delay in payments was unreasonable, they may have to pay up to 25% of the value of your delayed benefits payment on top of the benefits owed.  The penalty for unreasonable delay applies to any kind of delayed benefits, including disability, health insurance, death benefits, or any other kind of payments the insurer was obligated to make.  You must be able to demonstrate to a court that the delay was “unreasonable” in light of a variety of factors including the amount of the overdue payment, the length of the delay, any history of delayed payments, and whether there was any legitimate reason for the delay (such as legitimate administrative mistakes or setbacks).

Bad Faith Lawsuit

If your insurance company’s behavior is specifically designed to get you to drop your claim or accept less than the claim’s true value, then they may be engaging in illegal, bad faith conduct.  Bad faith conduct includes intentionally delaying benefits, intentionally delaying decision-making with regard to a claim, offering unreasonably low settlements without adequate justification, sending out burdensome and unnecessary requests for evidence, or deliberately misinterpreting either the language in the policy or the medical facts on the ground.

If your insurance company has engaged in bad faith conduct, you may have a claim for damages in civil court.  With the help of a bad faith insurance lawyer, you can file a suit seeking not only the full amount of the coverage you are due, but also additional damages based on the harm caused by the delay in full payment.

Gianelli & Morris is Ready to Help You Get the Benefits You Are Owed

If you are a California insurance policyholder or beneficiary and your claim has been underpaid or wrongfully denied, or if you have been subjected to bad faith conduct by an insurance company, call the insurance law attorneys Gianelli & Morris for a free consultation regarding your case.

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