After an accident, you may expect the at-fault party’s insurance company to cover your medical expenses, lost wages, property damage, and other losses. Unfortunately, insurance companies do not do what they should in every personal injury claim.
When a personal injury claim is denied, it can be frustrating and confusing, especially when you believe another person clearly caused your injuries. You may wonder whether a denied claim means you cannot recover compensation or whether you have other options.
The good news is that an insurance company’s decision is not necessarily the final word on your claim. Depending on the circumstances, you may be able to challenge the denial, provide additional evidence, negotiate with the insurer, or pursue legal action.
As a personal injury lawyer in Hamilton, Ohio, we know how difficult it can be for many people to navigate the ins and outs of insurance claims. It starts with understanding why insurance companies deny claims in the first place.
Why Do Insurance Companies Deny Personal Injury Claims?
There are many reasons why insurance companies deny personal injury claims. Some denials are based on legitimate questions about coverage or liability, while others result from disagreements over what happened, who was responsible, or how seriously someone was injured.
Remember that the insurance company is evaluating the claim from its own perspective. An adjuster may review police reports, medical records, photographs, witness statements, policy information, and other available evidence before deciding whether the company believes it is responsible for payment. If that evidence is incomplete or conflicting, the insurer may challenge or deny the claim.
Medical treatment is another common source of disagreement. An insurance company may argue that an injury was caused by a pre-existing condition rather than the accident. It may also question whether certain treatments were necessary or whether a delay in seeking medical attention suggests that the injury was less serious than claimed. These disagreements can arise even when you believe there is a clear connection between the accident and your injuries.
Liability can create similar disputes (click the link for a refresher on “what is legal liability“). An insurer may claim that its policyholder did not cause the accident or that you share some responsibility for what happened. There can also be questions about whether the applicable insurance policy actually covers the incident or whether required procedures and deadlines were followed.
Common reasons for denial include:
- Disputed liability
- Insufficient evidence
- Pre-existing conditions
- Delayed medical treatment
- Coverage disputes
- Missed deadlines
- Disputed damages
A denied claim does not necessarily mean the insurance company’s assessment is correct or that you have no other options. Understanding exactly why the claim was denied is an important first step toward determining how to respond. From there, it’s time to take action.
What to Do When Your Personal Injury Claim Is Denied
Having a personal injury claim denied can be frustrating, but it does not automatically mean your claim is over. An insurance company’s initial decision may be challenged, and there may still be options available for pursuing compensation.
It is also important to remember that most insurance adjusters are not attorneys. A personal injury attorney can review the reason for the denial, examine the available evidence and coverage, and help determine whether the insurance company’s position should be challenged.
With that in mind, there are several steps you can take to better understand the decision, protect your rights, and determine what options may still be available. Here are seven places to start.
Step 1: Read the Insurance Company’s Denial Carefully
If your claim has been denied, don’t immediately assume that the case is over.
Start by reviewing the denial letter carefully. The insurance company should generally explain the basis for its decision.
Look for information about:
- Why the claim was denied
- Whether the denial relates to liability or coverage
- Whether additional documentation is requested
- Whether you have an opportunity to appeal or reconsider the decision
- Any deadlines mentioned by the insurer
Keep the denial letter and any other correspondence you receive.
The reason for the denial can help determine what evidence or legal arguments may be needed to challenge the decision.
Step 2: Gather Evidence Supporting Your Claim
A denied insurance claim may sometimes be challenged by providing additional evidence. The most useful evidence will depend largely on why the insurance company denied the claim in the first place.
If liability is disputed, photographs, video footage, accident reports, and witness statements may help establish what happened. If the insurer questions your injuries or treatment, medical records can document your condition and its connection to the accident. Financial records can also help establish medical expenses, lost wages, property damage, and other losses.
Useful evidence may include:
- Accident reports
- Photos and videos
- Medical records
- Witness statements
- Financial records
- Insurance communications
The goal is not simply to provide more documentation, but to provide evidence that directly addresses the reason for the denial. An attorney can review the insurer’s decision, identify gaps in the available evidence, and determine what additional information may strengthen your claim.
Step 3: Continue Your Medical Treatment
If you were injured in an accident, continue following your healthcare provider’s recommendations.
Medical records can play an important role in establishing:
- That you were injured.
- The nature and severity of your injuries.
- What treatment you required.
- How the accident affected your health.
- Whether you may need future treatment.
Insurance companies sometimes point to gaps in medical treatment as a reason to question whether an injury was actually caused by an accident.
That doesn’t mean every delay in treatment invalidates a claim. There can be many legitimate reasons someone does not immediately seek treatment. However, following medical advice and keeping records of your treatment can help document your recovery.
The Richards Firm’s guide on how to document your injuries after an accident provides additional suggestions for keeping useful records throughout the process.
Step 4: Don’t Assume the Insurance Company’s Decision Is Final
An insurance company has a financial incentive to limit the amount it pays on claims.
A denial may reflect the insurer’s interpretation of the available evidence, but it does not necessarily establish that you have no legal claim.
For example, an insurer might deny a claim because it believes its policyholder was not at fault. Additional witness testimony, photographs, video footage, or accident reconstruction evidence could potentially provide a different picture.
Similarly, an insurer might argue that your injuries were unrelated to the accident. Medical records and testimony from healthcare professionals may provide evidence connecting your injuries to the incident.
The key is understanding why the claim was denied and whether the evidence supports the insurer’s position.
Step 5: Determine Whether You Have a Case
An insurance claim and a personal injury lawsuit do not necessarily go hand in hand.
A personal injury case generally involves determining whether another party was legally responsible for your injuries and whether you suffered damages as a result.
Factors that may be important include:
- Whether another party owed you a duty of care
- Whether that party breached the duty
- Whether the breach caused your injuries
- Whether you suffered compensable damages
- Whether another party is disputing responsibility
- Whether applicable legal deadlines have passed
If you’re unsure whether your circumstances support a legal claim, reviewing the situation with an attorney can provide clarity. If a claim can be made, you may be able to resolve it in lieu of filing a lawsuit. Unfortunately, there are times where filing suit to protect your rights becomes necessary.
The Richards Firm also offers a helpful resource explaining how to know if you have a personal injury case in Ohio.
Step 6: Be Careful About Speaking With the Insurance Company
After a claim is denied, an insurance company may continue communicating with you.
As always, you should be cautious about providing statements or signing documents without understanding their potential consequences.
Insurance representatives may ask questions about:
- How the accident occurred
- Your injuries
- Your previous medical history
- Your current treatment
- Your ability to work
- Your daily activities
It’s important to answer questions truthfully, but you should avoid guessing, speculating, or making statements you don’t fully understand. Better yet, talk to an attorney and avoid responding to an insurer until you do.
If you have concerns about how to communicate with the insurer, an attorney can handle those communications on your behalf.
Step 7: Consider Speaking With a Personal Injury Lawyer
If your claim has been denied and you believe another person was responsible for your injuries, it may be time to seek legal guidance. A personal injury lawyer can review the circumstances of your accident and the insurance company’s reason for denying your claim.
An attorney may be able to:
- Investigate the accident
- Gather additional evidence
- Review medical records
- Identify potentially responsible parties
- Communicate with insurance companies
- Challenge disputed liability
- Calculate your damages
- Negotiate a settlement
- File a lawsuit when appropriate
Legal representation can be particularly valuable when the insurance company disputes fault or claims your injuries are not related to the accident.
Can You Sue After a Personal Injury Claim is Denied?
In some circumstances, filing a lawsuit may be an option after an insurance claim has been denied. Whether litigation is appropriate depends on the reason for the denial, the available evidence, the extent of your injuries and damages, applicable insurance coverage, and who may ultimately be responsible.
A lawsuit is not always necessary. Many personal injury claims can be resolved through negotiations between the parties, insurance companies, and their attorneys.
However, having your personal injury claim denied not necessarily have to be the end of your claim. An attorney can evaluate the insurer’s decision, explain your available options, and determine whether further negotiations or litigation may be appropriate.
A Denied Claim Doesn’t Necessarily Mean Your Case Is Over
Receiving a denial from an insurance company can be discouraging, but it does not necessarily mean you have no options. Understanding why the claim was denied, gathering additional evidence, and continuing to document your injuries can help determine what steps may be available.
It is also important not to wait too long. Evidence can disappear, witnesses may become difficult to locate, and video footage may be erased or overwritten. Additionally, many bodily injury lawsuits must be filed within two years of the incident in the state of Ohio.
If you believe someone else’s negligence caused your injuries, speaking with a personal injury lawyer in Hamilton, Ohio can help you understand the insurance company’s decision and determine how to move forward.
At The Richards Firm, we help Ohio injury victims understand their rights and navigate disputes with insurance companies. If your claim has been denied, contact us to discuss what happened and what options may still be available.
If your personal injury claim has been denied, contact The Richards Firm to schedule a free consultation and discuss your legal options. We can be reached at 513-461-0084 or by visiting our contact page here.
