Personal injury lawyers can help you with a Kamuela injury claim denials by reviewing the decision, gathering additional evidence, filing an appeal, taking the insurer to court, negotiating a settlement, and litigating the case.
Insurance companies routinely deny valid injury claims—whether they stem from car accidents, slip-and-fall incidents, or workplace injuries. You do not have to accept a claim denial. You have the right to appeal, and you can file a lawsuit to gain the compensation you deserve.
Why Do Insurers Deny Claims in Kamuela?
Insurers deny claims for valid and invalid reasons. When an insurance company entirely denies liability, it must have a justification. The claims adjuster will cite the reason in the decision letter. But this is not the end of the road. The claimant can appeal. If the appeal is denied, he can file a lawsuit.
Here are some of the reasons insurers deny injury claims:
Lack of Coverage
The insurance policy may provide no coverage for the type of accident or injury that occurred. For example, a policy designed for auto coverage may offer no protection when the policyholder falls off a bicycle.
In another instance, a workers’ compensation insurer may claim a lack of coverage on the basis that the injury occurred somewhere other than the workplace or that the claimant is not an employee and, therefore, not protected.
Policy Exclusions
Most insurance policies have exclusions. These are situations that are beyond the scope of the policy and often include dangerous activities that the insurance company states in the policy are excluded. For example, a life insurance policy may exclude coverage for policyholders killed while skydiving.
Exclusions may include certain conditions, actions, or incidents.
Common exclusions include the following:
- Pre-existing Conditions
- Intentional Acts
- Criminal Acts
- Nuclear, Biological, Chemical, and Radiological Events
- Acts of War or Terrorism
- Earthquakes
- Dangerous Activities, such as drag racing.
Late Filing
Most policies have a time limit for filing a claim. Missing the filing deadline gives the insurance company a valid reason to deny the claim, but the decision can be overturned in certain instances.
For example, you can show that you gave the insurer timely notice. Also, you can argue that the delay was reasonable due to circumstances beyond your control, such as being incapacitated in the hospital. Further, policy language ambiguity opens the door to a successful appeal.
In some cases, the policy time limits go against laws and regulations. No company can write a policy that supersedes the law.
Also, if the insurance company has historically allowed late claims, you may have an appeal based on waiver or estoppel.
Insufficient Evidence
Insurance companies may deny the claim if it believes there is not enough evidence to prove the incident occurred as claimed. However, an insufficient evidence denial can be overcome by responding with further evidence or by disputing that the evidence submitted was insufficient.
In some situations, the insurer argues that the extent of the injuries has not been shown. We may overcome this with medical records and by arguing they do sufficiently demonstrate the severity of the injuries.
Disputed Liability
This reason is often cited in personal injury claim denials. The insurer disputes who was at fault in the accident. It may claim the injured party was at fault. Therefore, it has no liability.
Disputed liability is the most frequent reason that claims denials result in lawsuits.
Fraud Suspicions
When insurers suspect fraud, they will deny the claim. If this occurs, it’s crucial to understand the reason the insurer believes the claim is fraudulent. The denial letter should provide some explanation, but additional information may need to be sought.
It’s wise to consult an attorney who can review the claim’s denial and the claim itself. It’s possible that a misunderstanding or miscommunication caused the issue and that it can be resolved with a few letters or phone calls.
For instance, a rebuttal letter may result in a reversal of the decision. If not, you may win by appealing the decision to the insurance company. Finally, if the insurer continues to deny a valid claim, a lawsuit may be the only recourse.
The Appeals Process in Kamuela
Before taking the matter to court, you need to follow the insurer’s internal appeals process. This is an obligation that is a prerequisite to filing a lawsuit. Without going through this process, the insurer could argue that you failed to provide adequate opportunity to review the claim and, therefore, your lawsuit should be dismissed.
The claims denial letter should include the information you need to file an appeal, including the time limits and where to send an appeals letter. You may be able to appeal through the mail or online.
Succeeding with the appeals process begins with understanding the reasons for the denial, which the insurer should indicate in its denial letter. The adjuster must have had a valid reason to deny your claim. For instance, he cannot simply deny the claim with no explanation. Instead, he must cite a justification, such as disputed liability or a policy exclusion.
Before filing the appeal, gather supporting documents that can help build your case–for example, medical records, accident reports, photos, witness statements, and any other evidence that supports your claim.
With this evidence in hand, write a formal appeal letter. The letter should clearly state that you are appealing, explain why you believe the denial was wrong, and include all relevant supporting evidence. If applicable, quote parts of the insurance policy language that supports your position.
Once your appeal letter is ready, submit it to the insurance company according to the appeal process outlined in your policy. This usually requires sending the letter to a specific department or individual within the company.
Insurers have a specified time period to respond that is stipulated in their policy. For instance, many policies state the company will respond within 30 days.
Consulting an attorney is always wise before sending the appeal. Your attorney can help you define the arguments that are most likely to succeed and gather the evidence that will move the insurance company to overturn the decision. In addition, an attorney will prepare the appeal so that it serves as vital evidence if a lawsuit must be filed.
For instance, the attorney can formulate the appeal so that it demonstrates the legal basis for a lawsuit. As a result, the insurer may change the decision. Also, if the insurer remains intractable, then you have a solid basis for legal action.
Legal Action
Once the insurer denies your claim, your next step is filing a lawsuit. Your attorney will assess the facts of your case and on what grounds your lawsuit can succeed.
A lawsuit starts with a complaint. The complaint is a document filed with the court that initiates the lawsuit. It outlines the facts of your case, the legal basis for your claim, and what you are seeking in damages.
Since your lawsuit has its basis in the claim denial, your attorney will describe how the insurance company wrongly denied your claim and compounded that wrong by turning down your valid appeal, which was backed with strong evidence.
Once the complaint is prepared, it will be filed with the appropriate court. In Hawaii, this may be the district court or the circuit court, depending on the level of damages you are claiming.
After the complaint is filed, it needs to be served on the defendant, which is the insurance company in a claims denial case. Your attorney contracts with a process server for this service.
The defendant has a certain amount of time to respond, generally 20 days in Hawaii. In its response, the insurance company usually issues a blanket denial of your claims.
The initial stages of the lawsuit include discovery. During discovery, each side has the opportunity to initiate requests for documents, both from the other side and third parties. Each side must disclose its evidence to the other. No surprises are allowed in court.
Then the attorneys prepare written questions for the opposing side’s witnesses. Firstly, they ask the witnesses to affirm or deny material facts of the case. Then, they prepare interrogatories, which consist of a series of questions that the witnesses must answer under oath. Finally, the attorneys conduct depositions, which are face-to-face interviews with witnesses who are under oath. A stenographic record is kept.
During discovery, the parties may engage in settlement negotiations. As the discovery process proceeds, either side may uncover new information that strengthens or weakens its case. This impacts how much the insurance company is willing to offer and how much it will authorize to be spent fighting the case.
Lawsuits are expensive, and defending them suits deeply into the insurance company’s bottom line. As a result, the company is averse to spending money on a case it feels it will lose. As a result, once your attorney collects convincing evidence, the insurer is likely to agree to a reasonable settlement figure.
However, the process can take a year or more on average. During this time, insurers often hope that the plaintiff will grow tired of the process and accept a low settlement. Also, they know many plaintiffs may need the money and therefore be more likely to capitulate if the defense drags out the process.
Your Hawaii personal injury attorney fights back against these tactics. By preparing an unassailable case and negotiating to win, they convince the insurance company to settle the case or face losing at trial.
Talk to an Attorney Right Away in Kamuela
Olson & Sons specializes in fighting insurance claims denials in Hawaii. Our litigation team takes the fight to them. Don’t accept a wrongful claim denial. Contact Olson & Sons for a personal injury claims denial free consultation.
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