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  • Writer's pictureRobert Schuerger

What if the Claims Adjuster Denies Coverage for My Injury?

A victim of a personal injury matter will seek fair compensation for the injuries, property damage, and other areas that correspond to how they were affected. However, this is not a simple process.

The payment is expected to come from whichever company provides insurance coverage to the negligent party. However, the payment will not typically be very forthcoming. That's because insurance companies are more interested in protecting their interests than getting the victim the compensation that's needed.

Therefore, it's not uncommon for these firms to deny a car insurance claim once they can find an adequate reason to do so. When this happens, the party who submitted the injury claim can begin to panic since there will be questions surrounding what to do next. It is as if the insurance policy failed to do what it was meant to, correct?

It may not be that black and white in an accident claim. The information below is designed to help victims proceed after the negligent party's insurance company denied the claim that was submitted.

Elements of an Insurance Claim

Elements of an Insurance Claim

Personal injury claims are not characterized by arbitrary amounts. Instead, there should be a calculated and well-defined process to establish what is owed. The elements of the claim that are applicable will depend on the circumstances of the accident. A car accident will be used as an example here.

The negligent party should legally be covered by an auto insurance policy that will be responsible if the victim is successful in the settlement pursuit. Perhaps the accident that occurred left the victim unable to work and created a plethora of medical expenses.

Lost wages will be one of the key elements of the personal injury claim submitted against the negligent party's auto insurance company. After all, if the victim is now unable to work because of the accident when the person was employed and earning before it happened, considerations will need to be made for supplementing those lost wages.

Medical expenses are an even greater concern. The victim's best personal injury attorney will be looking to ensure that the claim includes existing spending, as well as any future spending that may come up. Some of the pieces of the medical expense puzzle include:

  • Prescription medication

  • Doctor's visits

  • Long-term carte

  • Physical therapy

  • Hospitalization costs.

Depending on the circumstances, there may be other elements applicable including pain and suffering, loss of enjoyment, property damage, etc. Considering the other party's insurance company will want to try to avoid dealing with these mounting costs as much as possible, it's not hard to see why anything that could be used to justify a denied claim will be used.

Why an Insurance Adjuster Might Deny Your Claim

Even your own insurance company would want to minimize its payout to you if you were at fault. Therefore, you shouldn't be too surprised when insurance adjusters who aren't on your side try their best to avoid having the claims process be favorable to you. Schuerger Shunnarah Trial Attorneys can answer questions like what does an insurance adjuster do?

When an insurance company denies your claim, there needs to be a reason. Here are a few of the common ones.

Liability Concerns

Liability disputes are some of the most popular reasons. Some accidents are very clear, making it easy to determine who is at fault and what needs to happen. However, others are not like that. For example, there are chain reaction accidents.

It's pretty common for a car accident to include two parties. However, there are chain reaction accidents that will involve more than two cars and as you can imagine, there can often be ambiguity on who and how many people are responsible.

In many cases, whichever vehicle was the first to crash into another will be at fault. However, what if tailgating makes that hard to discover who is at fault? The second vehicle may definitely have hit the first. However, did that happen because of force from being hit by the third? Maybe the second had already hit the first and the third only hit it because of the sudden stop.

Circular finger-pointing is not an uncommon tactic to either deny or delay insurance claims.

Non-policy Driver

There may be certain family members who were traditionally excluded from coverage because of bad driving history, and the verbiage used in policies would specifically exclude these people. However, things have taken a rather strange turn since the state of Texas took a "deregulation" turn.

This was meant to make things very clear on how insurance policies would work and who would be covered. While this is good for the consumer, insurance companies would prefer not to deal with that kind of straightforwardness since more ambiguity means an easier time avoiding liability.

Therefore, you now have a situation where there are often general exclusion causes that disqualify anyone not named from being covered, regardless of the circumstances that may have led to such persons driving.

Lack of Reporting

An insurance company will deny a claim if the driver covered did not report the accident. Of course, there is a strategy behind this too as you can imagine. Remember that these companies are looking for any reason to deny all or a part of the claim. The assumption is that in having a report filed, they can talk with the driver they represent and perhaps get information that can help in the pursuit of reduced liability.

There are reputable companies who will reach out to their drivers regardless, but others will make little to no attempt to reach out and then deny the claim because the driver was "non-cooperative" by not reporting the matter.

Injury Source Discrepancy

Causation is one of the fundamentals of personal injury cases. Not only does the affected party need to prove that the other was negligent and caused the accident, but there is also the matter of linking the injuries sustained to the accident.

If the insurance company has any reason to believe that there were pre-existing injuries or the ones being demonstrated were not a direct result of the accident, there may be attempts to deny coverage.

No Active Coverage

This one is self-explanatory and comes in two different forms. The first is a situation in which the coverage that would've covered the matter has simply elapsed. People can sometimes be late in renewing their insurance policies and any accidents that may happen during that uncovered period would not be the responsibility of the company.

Another way this applies is where the coverage that the policy affords simply does not cover the kind of claim that is being submitted.

Delayed Medical Treatment

The idea here is that the claimant did not get medical attention as soon as possible. The choice to delay the process of getting that treatment is assumed to have affected the current state of things. For example, imagine that there was a serious internal injury suffered but the claimant didn't seek any medical assistance because it didn't feel as if anything was wrong.

After a few weeks, some weird symptoms were noticed, which led to getting professional help, which revealed the internal injury, which is now worse than it needed to be.

Negotiations Can Break Down

Apart from the reasons above and others that may lead to a situation where the other party's insurance denied the claim, there may be a case in which the negotiation process simply breaks down. This could be due to unreasonable acts by the adjuster, avoiding your calls, sticking to a lowball offer, etc.

These are typical bad faith tactics, which are against state laws that require companies to act in good faith.

How Do You Deal with an Insurance Claim Denial?

How Do You Deal with an Insurance Claim Denial?

You don't have to roll over and accept the decision the company has taken to deny your claim. There will usually be an appeal process that you can follow that could lead to this decision being overturned. It is highly recommended that you retain the services of an experienced personal injury lawyer to maximize your chances of success.

There will be an evidence-gathering process to start things off. This will include eyewitness information, police reports, medical records, and more. Next, an appeal letter will be drafted to indicate the areas of disagreement, why each piece of evidence is being provided, why there should be coverage under the policy, etc.

Delaying Bringing in an Attorney Can Do More Harm Than Good

Remember that attorneys are familiar with underhanded tactics such as bad faith insurance practices that may be used to attempt to deny claims when that shouldn't be the case. This is one of many reasons it's a good idea to have an attorney present as early as possible to identify discrepancies and prevent you from taking steps that could jeopardize your claim. They can also help with explaining what damages are available in a personal injury case.

Talk to a Seasoned Personal Injury Lawyer Today

While the appeal process exists, navigating it alone is not easy or recommended. There must be a legal basis for the denial. It's essential to identify that basis or the lack thereof and begin the appeal from there.

A seasoned personal injury attorney in Houston can help you to achieve this. Schedule a free initial consultation today by calling Schuerger Shunnarah Trial Attorneys!


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