Insurance Claims & Asserting Your Legal Rights
An insurance claim is a formal request for payment. The insurance company reviews the validity of the claim and then pays the insured, or the person requesting payment on behalf of the insured. After assessing the circumstances of the claim, the insurance company either approves or rejects the claim. Claims cover everything from death benefits provided by life insurance policies to routine health exams under health insurance.
Filing an Insurance Claim
In order to file a claim for benefits under an insurance company, the insurance policy must be active. This means regular payments called premiums have been submitted in exchange for coverage. A missed payment can result in a lapsed policy.
The first step in filing an insurance claim is to contact the local representative of your insurance company. A specific agent will be responsible for investigating the details of the claim and negotiating payment from the main insurers. In some cases, the professional or recognized authority, such as a doctor in the case of a health insurance claim, or a building contractor for a homeowners’ insurance claim, can file the claim directly with the insurance company. In other situations, such as an automobile accident, you may contact the insurance company directly.
If you were injured in an accident or received negligent medical care, you may write a demand letter to the insurance company and include supporting documents. This letter would demonstrate liability by describing how the accident happened. You would also want to describe your injuries and medical treatment.
In the case of claims of damage, such as an automobile accident or damage to a house, for example, an adjuster or appraiser may be sent by the insurance company to evaluate the damage. The adjuster also determines if the repair estimates are reasonable. Preventing potential fraud is a priority. The contractor, for example, might inflate claim amounts in hopes of receiving additional compensation. The adjuster’s or appraiser’s evaluation is taken to be the final word by the insurance company. It is wise to wait to take your vehicle to a repair shop, for example, until you find out the insurance company’s policy on repairs.
It is important to remain honest about the details of an accident when filing insurance claims. In the event an insurance company determines you have lied to them about an aspect of an accident, they could deny your claim or even cancel your policy.
Rejected Insurance Claims and Negotiating for a Settlement
The insurance company may reject a claim made under the policy. If premiums have not been maintained, the policy may have lapsed and become inactive. Or another insurance company may have agreed to pay damages. This is typical of an automobile accident in which only one party is held responsible.
Another common reason for rejecting a claim is failure to fall under covered conditions. The insurance company can withhold payments for those accidents or damages caused by carelessness, or unavoidable “Acts of God,” for example. The policy spells out specific areas that qualify for benefits.
If you have written a demand letter requesting a fair settlement for your injuries, it may be important to negotiate the offer presented by the insurance adjuster. The adjuster should provide specific reasons for the amount of their offer. If you do reach an agreement with the insurance adjuster, confirm the agreement in a written letter to the adjuster.
