Can You Dispute an Insurance Claim Denial?

March 13, 2023

The answer is, yes, you can dispute an insurance claim denial. You have rights in Oklahoma and under federal law when your health insurance claim, auto insurance claim, home insurance claim or other insurance claim has been denied.

When you have faithfully paid your insurance premiums in order to be protected when unexpected health issues, accidents and other incidents occur and your claim is unfairly rejected, it can be very upsetting and frustrating. But you should not give up. In such cases, seeking assistance from Oklahoma City home insurance claim lawyers can be a crucial step. These professionals can guide you through the process of disputing the claim denial and help you get the coverage you need and have paid for.  There are steps you can take to dispute the claim denial and get the coverage you need and have paid for.

One of the steps to consider is engaging the assistance of an insurance denial attorney who can guide you right from the outset and potentially position you for a positive outcome.

What Happens if My Insurance Claim is Denied?

There are a variety of reasons that insurers of all types give for denying claims—sometimes they are valid, based on the terms of the policy. If an insurance company has a legitimate reason to not pay a claim, then it does not add up to bad faith. However, when claims are denied without a legitimate reason, insurance companies may be guilty of acting in bad faith, which basically means they are not fulfilling their obligations to their customers because their focus is on their bottom line instead of policyholders. In other words, the fewer claims these insurers have to pay, the more money they make.

Here are some examples of excuses insurers may make for denying different types of claims:

• Auto accident claim denial – The company could say that you were actually at fault for the crash or that the injuries you suffered were pre-existing.
• Homeowner’s insurance claim denial – One way an insurer might deny a homeowner’s insurance claim or lowball it is by asserting that poor maintenance to the property caused or contributed to the damage.
• Health insurance claim denial – Sometimes insurance companies will deny claims by saying the individual did not get the required preauthorization, or they may say a treatment isn’t medically necessary. Health insurance claim denials can leave ill or injured individuals in dire situations. Along with the physical and emotional stress of their health problem, they will also have to worry about how medical bills will be paid and may stop necessary treatments to avoid further bills.

You can see that there are various schemes insurance companies may use to deny claims. If your initial insurance claim has been denied, you can ask the insurer to reconsider its decision. Sometimes when insurers take a second look at a claim, they may discover that they overlooked important facts the first time or that they made an error and they will accept it and pay. Or sometimes when an insurer realizes that the policyholder is willing to push back against the unfair decision, especially if they know that the policyholder is working with a knowledgeable insurance attorney, they will decide to pay up rather than risk a possible court battle.

How Do I Dispute a Denied Insurance Claim?

To dispute a denied insurance claim, you can try contacting the agent who sold you the insurance policy if you have a specific agent you worked with. You can explain the claim denial to them and ask if they can help you in resolving the situation. You might also approach the agent’s supervisor or manager for assistance if the agent is unable or unwilling to look into the denial for you.

If that approach is unsuccessful, which it well could be, you can file an appeal with the company. The process for appealing should be included in your insurance benefits paperwork, although some insurers may bury this information to make it difficult for policyholders to find. If you cannot find it, call your insurer and ask them how to appeal.

Here are some tips for filing an internal appeal with the insurer:

• Be sure you get a specific reason for the claim denial in writing. If you don’t, call your insurer and request it. Always get the reason for the denial in writing, including the initial reason for denial and, should your appeal be denied, the specific reasons or reasons for that denial as well.
• Gather your policy and any related documentation. Review your policy to understand your benefits and what is covered and what is not covered.
• Write a letter to appeal the decision and keep copies of all documentation you provided in the appeal. If you mail the letter, send it certified mail so you have proof that it was received within the appeals time limit, which may vary by insurer. If you send the letter electronically, save the electronic record that shows the date and time it was sent.
• In your appeal, try to show the insurance company information they may have missed as to why your claim should be approved.
• Follow up on the status of your appeal regularly and keep records/written notes of all of your communications with insurance company representatives.

Finally, speak to an attorney who has experience in advocating for people in insurance claim denials, especially if you have a large and complex claim. An attorney who is used to handling insurance appeals can advise you throughout the appeals process and potentially greatly increase your chances of success.

Denied Health Insurance Claim or Coverage

While every type of insurance claim denial is frustrating, when you have a serious illness or injury, a denied health insurance claim for expensive treatment you have already had, or a denied pre-approval for care you need, is especially distressing. If your health is at stake, you need the insurance dispute resolved quickly. If your internal appeal with your health insurance company was unsuccessful, you may be eligible for an external review with an independent review organization. You can apply for such a review at the Oklahoma Insurance Department website. These third-party reviewers have no connection to insurance companies whose claim denials they are looking at. The decisions in these reviews are binding, meaning if your insurer is told to pay your claim or approve your medical treatment, they must do so. On the other hand, if you are still denied, your next option may be to file suit.

Additionally, if you have received a bill your insurer denied or underpaid because it is out-of-network and it is from a doctor, hospital or other medical provider you did not select, you may be protected under the No Surprises Act and your insurer may be required to pay. This federal act protects patients from surprise medical bills when they had no voice in making the decision for their care, such as in an emergency situation, for example.

Consider Filing a Legal Claim

If, after all your time and effort in trying to get your insurer to pay your claim or approve your medical treatment, you are still denied, you may be able to recover monetary damages through an insurance bad faith lawsuit, depending upon the strength of the evidence and facts in your case. An insurance bad faith attorney in Oklahoma can counsel you as to whether a lawsuit may make sense for you.

Damages Available in an Insurance Bad Faith Claim

If your insurer unfairly denied coverage for a valid claim, underpaid a valid claim, unnecessarily delayed payment or didn’t defend a claim made against you, such as in a car accident or premises liability case, and your appeal for reconsideration was denied, you may be able to get compensation through a bad faith claim. Compensation you could potentially receive in a bad faith lawsuit could exceed the amount of your original claim.

Damages in a bad faith insurance claim may include:

• Contract damages, which is payment of what the insurer owed under your original claim.
• Compensation for emotional distress, financial hardship and other issues you may have suffered due to the claim denial.
• Punitive damages meant to punish insurers and deter similar future behavior in cases of especially egregious behavior by the insurer.

You can learn more about your options for filing a bad faith claim by speaking with a knowledgeable Oklahoma insurance attorney.

Get Help from an Experienced Oklahoma Insurance Bad Faith Attorney

At Doug Terry Law in Oklahoma, our attorney focuses entirely on helping policyholders who are victims of insurance bad faith and insurance claim denials. He has more than 25 years of experience taking on the country’s largest insurance companies and has won millions of dollars for clients in health insurance, auto insurance and homeowner’s insurance bad faith claims. Insurers know Doug Terry and know that he is a tough opponent who will not back down in standing up aggressively for wronged policyholders. If you have a strong case for a bad faith lawsuit, he will fight hard to win.

Our law firm works on contingency, so we only get paid if we win your case. Contact us or call us today at 405-463-6362 for a free consultation so we can learn about your case and determinate the best way to proceed.