Actions You Should Take If Claim Adjuster Has Denied Coverage

Denial of certain claims allows any insurance company to remain a profitable enterprise. Each prospective claimant has a legal right to contest any denial of coverage.

Excuses offered by insurance companies when denying coverage

• The policy of the responsible driver does not cover the type of accident that has been reported.
• The policy of the responsible driver does not cover the reported injury.
• The driver’s policy has lapsed.
• The person driving the vehicle at the time of the accident was not covered, according to the policy’s terms.

Sometimes the adjuster might allege that the policy’s terms were unclear. Cayuga Personal Injury Lawyers realize that any ambiguities that might relate to a contract should be resolved in favor of the person that has signed that particular document.

What any claimant should realize, if he or she has been denied coverage:

The denial letter might come from the offices of the insurance company’s lawyer. That action does not mean that the company’s decision is binding.

Actions suggested for claimants that have received written notice that requested coverage has been denied:

Ask for a written explanation, and state that the same explanation ought to include a reference to the relevant policy provisions.

Await reply; if none provided, then compose your own letter to adjuster.

—Confirm date and nature of request made earlier, the request for a written explanation.
—Confirm the lack of response, the reason for composition of existing correspondence.

Wait again for a reply. If none has been offered, take one of 2 different actions:

—Write out a letter that provides details on the situation. Send that same letter to the State’s Insurance Commission. It should serve as evidence of the insurance company’s bad faith practices.
—File a lawsuit against the insurance company

Claimants have a legal right to continue the negotiations, even after being told about a denial of coverage.

As a claimant, your desire to exercise that legal right could be satisfied more easily, if you took the time to consult with a personal injury attorney. Follow these steps to start your appeals:

• Get your denial letter or a copy of it.
• Get a copy of your insurance policy
• Get a copy of your file from the insurance company
• Decide if you want to hire a lawyer
• Figure out exactly why your claim was denied
• Identify if your original claim (the one that was denied) had any gaps in information

Hire independent experts

• Order a functional capacity report
• Order a vocational expert report
• Order a medical expert report to support your disability
• Gather evidence in your report to support those gaps
• Missing medical records
• Written statements from your doctors
• Extra medical tests
• Written statements from non-medical experts
• Clarify parts of your original claim when necessary

You’ll need vocational experts if you’re filing for LTD benefits under any type of occupational policy. These policies define disability as not being able to work any type of job.

Build Your Case With Supporting Evidence

Your lawyer will take care of steps 5-8, and that’s why you should hire one. It might not hurt to help your lawyer out by doing the following:

• Clarify the functional limitations that your disability has caused you
• Clarify the precise requirements of your job, including the physical demands.
• Outline your work history in more detail
• Explain your disability keeps you from doing your job
• Give more new evidence for your diagnosis. This is how you will describe it in detail.

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