How to Handle a Wrongfully Denied Insurance Claim

Published on: 01/02/24 — In 

Having an insurance claim be wrongfully denied can be difficult and frustrating. To resolve the issue, it's important to know your rights and take the necessary steps. Here are some tips:

  • Read your health insurance policy or auto insurance coverage carefully.
  • Contact your health insurance company to find out why your claim was denied.
  • Stay calm and professional.
  • Gather supporting documents.
  • Appeal your medical treatment claim if needed.
  • File a complaint to the Department of Insurance if necessary.

These steps can help you resolve your denied health insurance carrier claim.

For additional help call Ktenas Injury Attorneys at (312) 300-2515 to discuss the insurance claims appeal process today. Our Chicago bad-faith insurance attorneys offer free consultations to review your case and discuss your legal options with you.

The Insurance Claim Process

The auto and health insurance providers' claim process can vary depending on different factors. It is important to read your health insurer's policy and explanation of benefits to understand the eligibility criteria and submission requirements.

Contact your insurance provider and inform them of the situation. They will review your auto or health plan policy and decide whether to accept or deny the claims for treatment. If you disagree with their decision, you can provide additional evidence to support your claim. This may include medical bills or property damage repair estimates.

If the auto or health care provider claim is still denied, you may need legal advice or file a complaint with the state's insurance department. The claim process can be lengthy, so patience and persistence are key.

a rejected insurance claim form on a desk

Denied auto or medical necessity insurance claims are frustrating and disheartening. Auto insurance or health insurance claim denial can happen due to administrative errors, missing information on claim forms, or the claim not being covered by the policy.

Knowing the types of denied insurance claims can help you prepare for what to expect when filing a claim. Providing inaccurate information on claim forms can disqualify you from coverage. Read your policy carefully to understand what may not be eligible for claims. Pre-existing conditions may be excluded from coverage.

Some policies may require additional evidence of losses. Insurance companies have strict deadlines for filing and processing claims, so review your policy for any time-sensitive requirements.

What to Do if You Think Your Claim Was Incorrectly Denied

If your insurance claim is denied, the first step is to understand your policy. Review the details to see if your request is covered. Look at the summary of benefits and exclusions for coverage. Read the entire policy to know all the requirements.

If you have questions, contact your insurer. If you are unsatisfied, contact an independent review organization or consumer assistance program to review your claim. You can then file an appeal with additional evidence. This could be medical bills or repair estimates. Your insurer will review and decide.

FAQ: How Long Does an Insurance Company Have to Pay a Claim?

If the appeal fails, seek legal advice or file a complaint with the state's insurance department.

Reading Your Insurance Policy

To file an insurance claim, be informed. Read your policy thoroughly to understand what's covered. Verify that your requested services/products are included. Be aware of deadlines/exclusions that could affect reimbursement. Provide the necessary information for an informed decision.

Common Reasons for Claim Denials

Insurance claims may be denied for various reasons. It's important to know these reasons so you can take steps to prevent denial. Inaccurate information is a common cause of denial.

Fill out claim forms accurately and completely to avoid this. Pre-existing conditions may also be excluded from coverage, so understand your policy's limitations when filing a claim for a pre-existing condition.

Determining the Reason for the Claim Denial

Insurance claim denials can be frustrating and time-consuming. To resolve the denial, start by understanding why it happened. Insurance companies must provide written notification with an explanation for the denial. This information will help you decide if you need to take further action.

Common reasons for insurance denials include inaccurate information, pre-existing condition exclusions, a gap in insurance coverage or the requested service/product not being covered by your policy.

How to Appeal a Wrongfully Denied Insurance Claim

If your insurance claim is denied, there are steps you can take to reverse it.

First, read the denial letter carefully to understand the reason for the denial. The letter should provide an explanation and any steps you can take to fix the issue. If possible hire a public insurance adjuster, and file an appeal with your insurance company by providing additional evidence to support your claim.

a blank insurance claim form, glasses, and pen on a desk

This evidence can include urgent care medical bills or repair estimates. If your appeal is unsuccessful, consider seeking legal advice or filing a complaint with the state's insurance commissioners. department. An attorney can help you file a bad-faith insurance lawsuit if needed.

Gathering Evidence and Documents to Support Your Appeal

To handle a denied insurance claim, gather evidence and documents to support your appeal. Provide proof to the insurance company that your claim should be accepted. Follow these tips: Review your policy carefully.

For health insurance denials gather medical records, including test results and doctor's notes. Collect receipts and estimates for reimbursement. Obtain statements from relevant parties to support your claim.

Submitting an Appeal to Your Insurance Company

If your insurance claim is denied, you can appeal it. You can review the denial letter to understand why it was denied. Gather all necessary evidence and documents to support your appeal.

Submit an appeal letter to your insurance company explaining why your claim should be accepted. Follow up regularly until you receive a response. If needed, contact the state's insurance department.

Following Up on Your Appeal with Internal Review or External Review

Getting a denial for your insurance claim from one of the giant insurance companies or commercial insurance companies can be disheartening. But don't worry, there are still things you can do.

  • Start by submitting an internal review of the denied claim to your insurance provider. They will check if they made a mistake or if there was a good reason for the denial.
  • If the internal review doesn't work, you can file an external review with the state's insurance department. This will provide a fair assessment of your claim.

Can an Attorney Help With a Wrongfully Denied Insurance Claim?

If your auto or health insurance claim file is denied, you may feel frustrated and helpless. You might not know where to start or how to appeal the auto or health care insurance decision.

But don't worry, Ktenas Injury Attorneys can assist you. Our experienced team understands the stress and frustration that comes with a denied claim. Our injury attorneys in Chicago will guide you through the appeals process, gather the evidence you need, and even represent you in court if needed.

Contact us now to get your insurance claim approved.