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What To Do If Your Insurance Company Refuses To Pay

What To Do If Your Insurance Company Refuses To PayInsurance companies often claim to have high ideals. In commercials, they promise to be there for you when you’re sick, help you after a car crash, or pay for repairs when a tree falls on your house. However, once you buy the policy and need to file a claim, many things can change.

While insurance companies claim to be motivated by protecting their customers, their real motivation is profit. This means they will usually try to pay out as little as possible, and often deny claims altogether. In recent research, hospitals are reporting a 6 to 13 percent denial rate for insurance claims submitted by patients.

The Buttafuoco & Associates blog has information about how to get the most out of your personal injury claim, but in this blog post, I’ll discuss actions you can take and what to keep in mind if your claim is denied altogether. If you are concerned about your insurer’s refusal to pay after your accident, get in touch with a New Jersey personal injury attorney at our firm. We may be able to help negotiate on your behalf so you can get the compensation you need to recover.

Do Not Accept the Denial as Final

Perhaps the most important thing to keep in mind if your insurance claim is denied is that an initial denial is not necessarily the end of the process. Any offer an insurance company makes–including a denial–is open for negotiation.

In fact, many insurance companies deny or make lowball offers on valid claims because they expect that many of their customers will simply give up, thereby saving them the cost of paying out the injury claims. If you are uncomfortable negotiating with your insurance company, we recommend working with an experienced Northern New Jersey personal injury attorney to give yourself the best chance of appealing the denial.

Find Out Why Your Claim Was Denied

To negotiate or appeal the denial, understanding the insurance company’s rationale is essential. If the explanation is unclear in their letter or other statement, request more detail in writing. In the case of health insurance, for example, the New Jersey Department of Banking and Insurance describes two types: 1) Utilization Management Denials (UM denials) and 2) Administrative Denials.

  1. UM Denials: This type of denial occurs because the insurance company determined that the medical procedure was not covered under the insurance policy. Some of the common rationales are that the procedure was cosmetic, experimental, or medically unnecessary. In the case of a UM denial, it’s important to build a detailed case to refute their reasoning.
  2. Administrative Denials: Many claims are denied for reasons that have nothing to do with the policy, such as submitting the wrong forms or sending a claim to the wrong department; these are administrative denials. Insurance claims require a significant amount of paperwork, which means errors that result in denials are not uncommon. At Buttafuoco & Associates, we find that even if your claim is denied for administrative reasons, there is legal recourse for you. An insurance adjuster who fills out a form incorrectly or files paperwork late should not keep you from getting your life back on track.

While this terminology is specific to medical insurance, there are similar denials in other types of insurance industries, including auto insurance, homeowners insurance, life insurance and liability insurance. Essentially the insurance company may deny the type of claim because they say it was not covered by the policy or for administrative reasons. Each type of case has different legal options, and Buttafuoco & Associates’ experienced insurance claim attorneys in Northern New Jersey can help you navigate the appeal and negotiation.

Department of Banking and Insurance

If you or your Northern New Jersey insurance claim lawyer believes your insurance company has denied your claim illegally, acting in conflict with consumer protection regulation, you have additional resources for your case. You and your team can file a complaint with the New Jersey Department of Banking and Insurance. If there are grounds for further investigation, this will strengthen your case.

As you can imagine, these cases are quite complicated, so working with an attorney is key to getting the settlement you deserve and making a full recovery after a car accident. Our team offers free consultations where we can clarify your rights, determine whether you have a case, and advise you on next steps.

If your claim is denied, don’t back down. Call Buttafuoco & Associates today at 1-800-NOW-HURT.


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