My Claim Was Simple, but My Insurance Company Still Denied It. What Happened?
Whether your insurance claim is simple or complicated, it could get denied by your insurance company for a variety of reasons. There might be a small, easily-correctable mistake made by your insurance company or by yourself when filing your claim, your insurer may assert that your claim falls under an exclusion, or they may argue that there was a problem with your initial insurance application. Even if you believe your claim is simple, your insurer might have reason to deny your claim, although that reason may or may not be valid.
Incorrect or Incomplete Claim
Your claim may have been denied based on a problem with your claim submission. You may have neglected to include sufficient documentation or other evidence supporting your claim, such as medical records or physician recommendations. You may have simply left certain parts of your claim form blank, or included incorrect information. Your claim denial letter should notify you of the reason for the denial; there is a chance it is something very simple that can be easily remedied by correcting a form or providing additional information.
Your Company Made a Mistake
Insurance companies make mistakes. They may have erroneously denied your claim based on a clerical error. A simple phone call or letter may be able to resolve your claim. Failing that, seeking a proper internal appeal may cause the company to realize their mistake and quickly overturn their denial.
If you miss premium payments, your insurer might let your policy lapse. Typically, you have a grace period of between 30 and 90 days after a due date to correct your missed payment without your policy lapsing, and your insurance company should notify you of the problem before letting your policy lapse. If your claim arises after your policy lapses, even if relatively soon afterward, your insurer is likely to deny your claim.
Alleged Problems With Your Initial Application
If your original insurance application included material (important) misleading information or omissions, such as misleading statements about your health, family history, or habits, then your insurance company might be able to rescind your policy. Rescission declares that your policy was invalid when entered, based on the false information in the application. Unfortunately, depending on the circumstances, they sometimes wait to investigate your application until after you file a claim and only then decide that your policy was invalid this whole time. Depending on the type of policy, rescission may only be available for a certain number of years after the policy is issued.
Policy Exclusions and Other Reasons for Denial
All insurance policies carry exclusions. Life insurance policies often exclude certain causes of death, such as suicide, death during the commission of a felony, or death while performing a dangerous activity such as skydiving. Health insurance policies typically exclude cosmetic and other medically unnecessary procedures. Disability insurance sets strict requirements to prove disability. Check your policy language and the denial letter to identify whether your claim falls under a policy exclusion. Your insurer might erroneously claim that your claim falls under an exclusion, and their misread of your policy or your medical condition could be either accidental or an intentional, bad faith maneuver to avoid a payout.
Your company may assert other policy-based reasons to deny a claim. Your health or disability claim might be denied if your injury was self-inflicted, if you failed to obtain medical treatment within a reasonable time frame, or if you behaved after your injury in such a manner as to make your injury worse. Review your denial letter for a clear answer as to why your claim was denied in order to prepare a proper response, appeal, and file legal claims where appropriate.
Gianelli & Morris Provides Trusted Advice and Representation for California Policyholders and Beneficiaries Wrongfully Denied Coverage
For help responding to a wrongful claim denial, or for help with any other problems regarding your California life, health, or disability insurance policy, call the California insurance coverage denial attorneys Gianelli & Morris for a complimentary, confidential consultation.