What to Do If Your Personal Injury Claim Is Denied

Understand Why Your Claim Was Denied

Insurance companies deny personal injury claims for various reasons. Identifying the exact cause is the first step toward addressing the issue. Common reasons include:

• Lack of Evidence: Insufficient medical records, police reports, or witness statements.
• Disputed Liability: The insurer claims you were at fault or partially responsible.
• Missed Deadlines: Failing to file within the statute of limitations or missing insurer-imposed deadlines.
• Pre-Existing Conditions: The insurer argues your injury existed before the accident.
• Policy Exclusions: The claim falls outside the coverage terms.

Request a written denial letter from the insurer, detailing their reasoning. This document is crucial for your next steps.

Review the Denial Letter Carefully

Insurance companies must provide a written explanation for denying a claim. Scrutinize the letter for:

• Specific Reasons for Denial: Look for inconsistencies or vague justifications.
• Cited Policy Provisions: Verify whether the insurer correctly applied the policy terms.
• Procedural Errors: Check if they followed proper claim-handling protocols.

If the denial appears unjustified, you may have grounds for an appeal or legal action.

Gather Additional Evidence

Strengthen your case by collecting more documentation:

• Medical Records: Obtain detailed reports from doctors, physical therapists, and specialists linking your injuries to the accident.
• Expert Testimony: Hire medical experts or accident reconstruction specialists to validate your claim.
• Witness Statements: Secure affidavits from bystanders or experts supporting your version of events.
• Photographic/Video Evidence: Provide clear images of the accident scene, injuries, and property damage.
• Employment Records: If claiming lost wages, submit pay stubs, tax returns, and employer verification.

File an Appeal with the Insurance Company

Most insurers have an internal appeals process. Follow these steps:

1. Submit a Written Appeal: Clearly state why the denial was incorrect, referencing policy clauses and new evidence.
2. Meet Deadlines: Adhere to the insurer’s appeal timeframe (usually 30–60 days).
3. Follow Up: Track correspondence and confirm receipt of your appeal.

If the insurer upholds the denial, escalate the matter to a higher authority, such as your state’s insurance regulator.

Consider Alternative Dispute Resolution (ADR)

If appeals fail, ADR methods like mediation or arbitration may resolve the dispute without litigation:

• Mediation: A neutral mediator helps negotiate a settlement. Non-binding but often effective.
• Arbitration: An arbitrator reviews evidence and issues a binding decision.

ADR is typically faster and less expensive than court proceedings.

Consult a Personal Injury Attorney

If your claim remains unresolved, hiring an attorney improves your chances of success. A lawyer can:

• Evaluate Your Case: Determine if the denial was wrongful and assess legal options.
• Negotiate with Insurers: Leverage legal expertise to push for a fair settlement.
• File a Lawsuit: If necessary, initiate litigation before the statute of limitations expires.

Most personal injury attorneys work on a contingency basis, meaning you only pay if they win your case.

File a Complaint with the State Insurance Department

If the insurer acted in bad faith (e.g., unreasonably delaying or denying claims), file a complaint with your state’s insurance regulator. They can investigate and penalize misconduct.

Take Legal Action

If all else fails, sue the at-fault party or insurer. Steps include:

1. Drafting a Complaint: Outline your injuries, damages, and legal basis for compensation.
2. Discovery Phase: Exchange evidence with the defendant through depositions and document requests.
3. Settlement Negotiations: Many cases settle before trial.
4. Trial: Present your case to a judge or jury if no settlement is reached.

Prevent Future Claim Denials

To avoid denials in future claims:

• Report Accidents Immediately: Notify insurers promptly.
• Document Everything: Keep records of medical visits, repairs, and correspondence.
• Follow Medical Advice: Adhere to treatment plans to prevent disputes over injury severity.
• Understand Your Policy: Know coverage limits, exclusions, and claim procedures.

Final Considerations

While claim denials are frustrating, persistence often pays off. By methodically addressing the insurer’s objections, gathering robust evidence, and leveraging legal resources, you can maximize your chances of securing fair compensation.