If you’ve been injured in an accident, it’s important that you seek medical treatment right away. Delayed medical treatment may result in further health complications and permanent damage. Some people fear the idea of racking up hospital bills only to have their injury claim denied by an insurance company.
However, understanding why insurance companies deny claims can help alleviate this fear and ensure you are better prepared to take the necessary steps to protect your rights.
Important Stats About Insurance Claims
Before we answer the question “why do insurance companies deny claims,” you may be wondering how common are denied claims? We’ve gather a few statistics about insurance claim denial in the US that provide insight into the situation as a whole.
- About 15% of all insurance claims are denied on average.
According to a study from the American Medical Association (AMA), around 15% of claims submitted to health insurance companies are denied. This percentage can vary based on the specific insurer and type of insurance. - Nearly 18% of adults have had a claim denied in the past year.
According to KFF, 1 in 5 adults experience a denied claim each year. 80% of these people found their insurance policies were difficult to understand. - 58% of insured adults have experienced insurance problems.
Another study by KFF showed that over half of insured adults experience problems when trying to use their health insurance. In addition to denied claims, this could include delayed payments, underpayment, and more. - Less than 0.2% of denied claims are appealed
HealthCare.gov showed that less than a percent of denied claims are appealed. Those who do appeal, however, typically have a 50% chance of winning.
But Why Do Insurance Companies Deny Claims?
In personal injury cases, insurance companies are typically responsible for covering the costs associated with injuries caused by the negligence of their insured. Whether it’s a property and casualty, business, or homeowners’ policy, there are various types of coverage available to help you during an already difficult time.
However, insurance companies are known to sometimes deny claims, leaving many accident victims frustrated and unsure of what to do next.
Why do insurance companies deny claims when that’s the entire reason for having insurance? Is it because they’re evil organizations dedicated to ripping off their own customers? No. Insurance companies are trying to turn a profit, so sometimes a denial is done in bad faith. That said, the world of accidents and injuries is very complex, and people aren’t always transparent with the details. Because of this, insurance policies have been increasingly in what they do and do not cover.
When a claim doesn’t appear to align with the terms of a particular policy, it may be denied.
Delayed Treatment
One common cause of insurance claim denial is delayed medical treatment. The longer you wait to see a doctor after an accident or injury, the more skeptical the insurance company becomes about the legitimacy of your claim.
They may argue that your injuries were not caused by the accident in question, or that they were not as severe as you are claiming. Alternatively, going untreated for an extended period of time can result in your injuries becoming worse than they otherwise would have been.
This could require additional treatments and visits, which cost more money than it would have if you immediately sought medical treatment.
This is why it’s crucial to seek medical attention immediately after an accident. Not only does it protect your health, but it also strengthens your claim by establishing a clear link between the accident and your injuries.
Preexisting Conditions
In addition to delayed treatment, preexisting conditions can also lead to denied claims. Insurance companies will often review your medical history to find any existing conditions that may overlap with your current injuries. They might argue that your injuries were not caused by the accident but rather were a result of an issue that was already present.
For example, if you have a history of back pain and are involved in a car accident that causes further back injuries, the insurance company may claim that your current issues are simply a continuation of your preexisting condition. This can be incredibly frustrating, especially when you know that the accident worsened your health.
Insufficient Proof
Another common reason for claim denials is insufficient proof of injuries. When filing an injury claim, it’s not enough to simply tell the insurance company that you’re hurt. You need to provide clear and detailed documentation of your injuries, including medical records, doctor’s notes, and even photographs of visible injuries.
The more evidence you have, the stronger your case will be.
Without this documentation, the insurance company may doubt the severity of your injuries and the causes of the accident, resulting in them either underpaying or denying your claim outright.
The insurance company may also argue that the accident was avoidable and that you are partially/fully to blame for what happened. For instance, they may assume that you were not paying attention to your surroundings. This is why it’s important to gather as much evidence as possible at the scene of the accident, including witness statements, photos, and detailed notes about what happened.
The more information you can provide to refute these claims, the better your chances of receiving the compensation you deserve.
Expired Insurance
Sometimes people are injured only to discover that their insurance has lapsed or expired. It’s easy to forget about the status of your insurance when you’re not using it. Though this situation can be distressing, it’s important to know that you may still have options. In some cases, you may be able to reinstate your coverage by paying a fee, allowing you to receive the benefits you’re entitled to in the future.
What Can You Do When Insurance Companies Deny Claims?
If you’ve received a claim denial, don’t panic. While it can feel like an overwhelming setback, a denied claim doesn’t have to be the final word on the matter. Insurance companies and their adjusters are trained to minimize payouts, spot faulty claims, and deny claims that don’t align with a given policy. Why do insurance companies deny claims? It’s not because they’re malicious. They are simply doing their job.
They’re also eager to finalize claims as quickly as possible, which can lead to underpayment, especially when you need ongoing treatment. By doing this, they limit their financial liability, leaving you with the burden of paying for additional care out of pocket.
While you should always seek medical attention immediately, you shouldn’t simply settle for the first response from an insurance company. Whether they’ve outright denied your claim, or you feel they’re undercovering you, you have options. This is where a personal injury attorney can help.
Speaking to an Attorney About a Denied Insurance Claim
After an accident, the first thing you should do is seek the appropriate medical attention. The second thing you should do is speak to a trustworthy injury attorney. A personal injury lawyer can review your case, discuss options, gather additional evidence, and negotiate with the insurance company on your behalf.
Simply providing more evidence and communicating through an attorney can often be enough persuade the insurance company to change their decision. In addition to gathering evidence, they can help attain input and testimonials from experts. For example, if they denied your claim due to a preexisting condition, your attorney may be able to gather professional medical opinions that show how the accident directly caused or worsened your injuries.
It’s also worth noting that insurance companies are bound by legal obligations to act in good faith when handling claims. On the list “why do insurance companies deny claims”, they cannot unfairly delay, deny, or underpay claims without a valid reason. If you believe that the insurance company has acted in bad faith, your attorney may be able to pursue legal action to hold them accountable. This can include filing a lawsuit for bad faith insurance practices, which could result in additional compensation for you.
Additionally, if your insurance has lapsed or expired, don’t lose hope. Depending on your circumstances, you may be able to have your policy reinstated, allowing you to move forward with your claim. An attorney can help you navigate this process and explore all available options for getting the coverage you need.
For a personal injury lawyer in Hamilton and Cincinnati, Ohio, contact The Richards Firm today. Your initial consultation is free, which means you should call us if only for peace of mind. During your consultation, we can learn more about your situation, help you organize your options, and ultimately suggest next steps to you.
A denied claim doesn’t have to be the end of the story. Contact The Richards Firm to take control of your situation.