Denied Insurance Claims

Denied Insurance Claims

Insights From a Columbus Insurance Claim Denial Lawyer

Denied insurance claims leave policyholders victimized twice—first by the accident, illness, or weather disaster, and second by learning that policies they have counted on to see them through some of their worst periods have no real value. Appealing a claim denial is always possible, but doing so without assistance from a Columbus consumer protection attorney can make convincing an insurance company to change its negative coverage decision difficult.

Insurance contracts include dense, legalistic language and extensive lists of exclusions designed explicitly to limit insurers’ obligations to pay out on claims. Companies will also often take great pains to portray a policyholder as being primarily at fault for causing any injury, death, motor vehicle accident, or property damage. Dealing with such tactics requires producing evidence that judges and juries cannot dispute no matter how hard insurers try to call the proof into question. Ohio residents facing that challenge can find the legal expert and advocate they need in a Leist Warner civil litigation lawyer.


Top Explanations Insurers Give for Denying Claims

Claim denials can sometimes look automatic. Laws and contract provisions in policy documents do, however, require companies to explain why they have reached an initial decision to turn down a coverage request or benefits payment. Organized by type of insurance, here are some of the most frequent reasons insurers give for denying claims.


Auto Insurance Claim Denials

  • Policyholder bears the most responsibility for causing a wreck.
  • Preexisting health problems caused more problems than the crash.
  • Police reports and medical records were not filed in a ‘timely’ manner, with the definition of timeliness varying greatly.
  • Diagnosis or opinion from the policyholder’s doctor(s) differs from those of physicians paid by the insurance company.


Health Insurance Claim Denials

  • Patient is misidentified on medical records and/or billing statements.
  • Claimant failed to keep coverage current by missing premium payments.
  • Required preauthorization for a procedure or prescription was not obtained.
  • Care provided falls under the list of exclusions.


Life Insurance Claim Denials

  • Policyholder failed to completely disclose his or her health history (e.g., previous diagnoses, surgeries, family history of cancer), which insurers call “making material misrepresentations.”
  • Unpaid premiums.
  • Suspected foul play by beneficiaries, even without evidence of a criminal investigation.
  • Cause of death falls under list of exclusions (e.g., suicide, a reckless act such as BASE jumping).


Homeowners/Renters Insurance Claim Denials

  • Flooding of a privately owned home caused by weather events unless a flood policy exists (renters insurance generally covers flooding).
  • General wear and tear, meaning the bursting of a 100-year-old pipe may not be covered without a claim denial appeal.
  • Earthquake damage without a special provision.
  • Depreciation, meaning an insurance claims adjuster assigns a much lower value on replacing or repairing items than the policyholder would.


Ohio Does Not Deny Recovery on Contributory Fault

One of the most important grounds for appealing an insurance claim denial exists when the policyholder bears less than 50 percent of the responsibility for the incident that created the need to invoke coverage. Ohio state law and civil courts recognize that accident victims deserve insurance benefits and compensation for damages or injuries even if they are somewhat liable for causing an accident or failing to fully protect themselves and their property. This principal, called either contributory fault or contributory negligence, allows for the settlement of insurance claims as long as a beneficiary is not principally responsible for causing the claimed harm.


Do Not Accept an Insurance Claim Denial as a Final Answer

Attorneys at Leist Warner have helped many people win reversals of insurance claim denials. If you need assistance with your policyholder dispute, contact us online or call (614) 222-1000 to schedule a no-cost case evaluation.

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