What Happens If Your Insurance Claim is Denied
Bill Allen | December 10, 2020 | Car Accidents
You pay your insurance premiums on time each month. So, when you are in a car accident, you expect your insurance company to be there for you. You expect that your medical bills are paid, and your lost wages are reimbursed.
However, many people are shocked to discover that their no-fault car insurance policy does not cover all of their medical bills or lost wages. Worse yet, other people injured in car accidents receive denial of claim letters from their insurance providers.
If you are in the second group, you might be shocked. One of the benefits of living in a state that requires no-fault insurance is prompt payment of claims, regardless of which driver caused the car accident. Unfortunately, insurance companies treat all claims the same way – they try to find ways to deny or undervalue the claims to save money.
What are Florida’s No-Fault Insurance Requirements?
Drivers in Florida must purchase at least $10,000 in Personal Injury Protection (PIP) insurance coverage. PIP is a no-fault insurance policy. It pays benefits to the insured after a car accident, even if the insured caused the car accident.
Drivers injured in a car wreck file insurance claims with their insurance company after an accident. Their PIP insurance pays 80 percent of reasonable and necessary medical care for accident injuries. It will also reimburse the driver for up to 60 percent of lost wages.
Individuals who sustain serious injuries can pursue a claim against the at-fault driver. Serious injuries are defined in Florida’s insurance laws. If you have a serious injury, you may want to pursue a personal injury claim to recover compensation for damages that PIP insurance does not cover.
A claim against the at-fault driver could result in compensation for all lost income and all medical expenses. You can also recover compensation for your pain and suffering damages. Pain and suffering damages include:
- Physical pain and suffering
- Emotional distress
- Psychological damages
- Disabilities and permanent impairments
- Mental trauma and anguish
- Loss of enjoyment of life
- Other out-of-pocket expenses
If your injuries do not meet the serious injury threshold, you are limited to your PIP policy’s benefits.
Why Was Your PIP Claim Denied?
When you submit your claim to your insurance company, the company assigns a claims adjuster to the case. The adjuster reviews your claim. If there are any problems, the adjuster could deny your car accident claim.
Some reasons that your insurance company could give for denying your PIP claim include:
- You did not seek medical care for your injuries within 14 days from the date of the car crash as required by your PIP policy
- You received treatment from someone other than a licensed physician or medical facility
- The medical treatment received was not reasonable or necessary for your condition
- The car accident did not cause your injuries
- Your injuries were not an emergency medical condition that would qualify for compensation up to your policy limits
- You intentionally caused the accident or were driving under the influence of alcohol or drugs
- Your injuries were related to a pre-existing condition or prior accident
- The vehicle was stolen, or you were committing a felony at the time of the accident
- Your PIP policy did not cover the injuries or accident
If you receive a denial letter, review the letter carefully. You have a deadline for filing an appeal of your insurance denial.
Appealing the Denial of Your PIP Insurance Claim
The denial letter should provide instructions for filing a request for an internal review and the deadline for filing the request. The request must be submitted to the insurance company according to the instructions in the denial letter.
The denial letter should also explain the reason for the denial. You might be able to provide additional information or documentation to clear up the problem.
An internal review requires that another insurance adjuster review and process the claim. Once the second adjuster reviews the claim, you will receive another letter explaining the decision. If your PIP claim is denied a second time, you might want to talk with a car accident lawyer.
The insurance company could be acting in bad faith by denying the claim. Even if the insurance company is not acting in bad faith, the insurance company could have made a mistake in denying your claim.
Filing a lawsuit for an insurance denial could result in receiving the compensation you should have received for your insurance claim. You might also receive compensation for any losses caused by the insurance company wrongfully denying your car accident claim.