How to Appeal an Insurance Claim
Insurance companies sell insurance that will help us recover costs and expenses should we experience an unexpected loss. We buy insurance in good faith and each year renew our premiums without hesitation. Many of us will have to file a claim at some time in our lives but we take comfort knowing that we have protected ourselves and our families from economic disaster. Unfortunately, many of us will also have our claims denied and will have to figure out how to file an appeal with an insurance company. No one should have to file an appeal but remember that the insurance companies pay adjusters to keep claims to a minimum. The longer insurance companies make us wait, or fight for what we are entitled to, the more money they make at our expense. The good news – there is help available.
Types of Insurance Claims
- Life Insurance Policy
- Injury / Accident
- Long Term Disability
- Critical Illness
Common reasons claims are denied by insurance companies.
- Failure to pay premiums.
- Policy exclusions
- Missed deadlines for filing your claim.
- Errors in your application
- Unknown pre-existing conditions or failure to disclose pre-existing conditions in your policy.
- Employer information did not correspond with your claim.
- Medical doctor did not state that your disability prevented you from working.
- Refusal to attend treatments or medical assessments by insurance company.
- Not regularly seeking medical follow up
- Your injury does not fit the description of disability as defined by your insurance company.
- Misrepresentation of disability – for example: Social Media posts showing a life you claim you do not have any longer.
How to file an appeal with an insurance company
If you have received a letter stating that your claim is denied, ask your insurance provider to send a written letter detailing the reasons behind their decision. Next, read the notice and reasoning carefully, review your policy in relation to your claim details and then read into the fine print. This can be complicated, and we would recommend seeking legal advice. An insurance lawyer has the experience to read the policy wording and its interpretation. They can then determine if the insurance company has errored in its decision and what action you should take. Lawyers are also capable of determining what your entitled to receive based on your policy terms in relation to your loss. An insurance lawyer will also calculate what you will need to live financially and medically supported over the course of your lifetime.
Steps to filing an insurance claim appeal.
There is a very specific procedure that you must follow when disputing a claim. It is important to follow the appeal steps outlined in your policy while paying strict attention to the timelines.
- Review your policy – look at the details and see how they apply in your situation.
- Locate in the policy or on the website the Insurance Companies Appeal process and contact information.
- Phone in your complaint
- Write a letter of appeal.
- Request the appeal to go to a higher authority.
- File a complaint with the Ombudsman.
- Hire a lawyer.
Things you should know about appealing an insurance claim
- Insurance companies have strict timelines for filing claims and appeals.
- If you miss the deadlines your claim may have no recourse even though you are entitled to compensation.
- Appealing a decision can take months and sometimes years.
- If you are not working you could face financial hardships.
- If you are not successful in appealing the decision, there is a timeline for filing a lawsuit against the insurance company.
- Timelines are strict and often start from the time the denial letter was sent to you – not from the day you received it.
- Insurance companies may request additional medical evidence that may influence your claim.
When should I consult a lawyer?
The best time to speak to a lawyer is when you are filing your claim just after your loss. But if you have submitted a claim, you should seek legal counsel immediately after your claim is denied or if a settlement is offered quickly. Timelines for filing a lawsuit, after a claim is denied, is typically 2 years but there may be clauses in your policy that reduce this time. A lawyer would be responsible for meeting those timelines on your behalf. If you want to read more about this, you can refer to the Limitation Act .
What can you sue for?
- Bad faith
- Pre and post judgment interest on the amounts claimed.
- Legal fees – all or some
- The payment you are entitled to.
Who is responsible for coverage and how much?
If you have multiple insurance policies, you may be able to make a claim under more than just one. It is important to note that the job of the insurance adjuster is to make sure that they insurance company pays as little as possible on your claim. They are friendly and helpful but remember they do not act on your behalf. Insurance adjusters are often only authorized to payout claims to a certain amount. If your claim exceeds that amount, they will have to take it to a claim supervisor.
Vancouver Insurance Lawyer
Wishart Brain and Spine Law is a personal injury law firm that focuses on complex injury claims such as TBI and SCI, wrongful death, long term disability claims, and Medical Assistance in Dying. We do our absolute best to help you get the best settlement and care possible.
What sets us apart from other insurance law firms.
Robyn Wishart used to represent the insurance companies and knows how insurance companies operate from the inside. The team at Wishart Brain and Spine Law are here to fight for you. Your focus should be on recovery not a complex legal struggle. We offer a free consultation to help you decide what course of action is best for you and your family.