Insurance Claims

INSURANCE CLAIMS

Insurance Company Tactics

Insurance companies have many tricks in their toolbox to wrongfully deny claims.  These may include the following:

  • Not giving you the straight scoop.  The insurance company does not let you know the specific insurance policy section upon which it bases its denial.
  • Not giving you the policy.  The insurance company may refuse or fail to provide you with copies of the policies upon which it bases its denial of coverage.
  • Not meeting with you.  The insurance company may fail to actually meet with you before denying the claim.
  • Making up policy language.  The insurance company may even quote language that it claims is from the policy but actually does not exist in the policy.
  • Misrepresentation.  The insurance company may misrepresent or fail to include the specific facts of the claim, which support its denial.
  • Early denial.  Insurance company may deny the claim and then ask for more information hoping that additional information will support their denial of the claim.
  • Relying on the wrong policy language.  The insurance company may refer to portions of the policy that do not apply to the facts of your case.
  • Scare you.  The insurance company may attempt to frighten you by suggesting that they are reserving rights to assert policy defenses after the denial of coverage.

The Parts of an Insurance Contract

There are three parts, which are basic to most insurance contracts.

  • Application.  The application is the written information, which contains the questions the insurance company wants to know from you regarding its potential risks.
  • The Declaration Page.  The declarations page is a written document which tells you the policyholder's name, a description and location of either the person or property which is insured, the amount of insurance policy limits, the deductibles and any potential endorsements that may limit or expand the insurance coverage.
  • The Policy.  The policy is a written booklet that contains the insurance agreement, including the definitions of the words used within the agreement, any conditions that may apply, exclusions and written endorsements that may limit or expand available insurance coverage, and typically the policy will set forth the duties and responsibilities of you and your insurance company.

What do Insurance Adjusters do for Insurance Companies?

Insurance Adjuster.  The first function of a claims representative is typically to control and gain your trust before you become a plaintiff.

Typically, the claims adjuster will make early contact with you in an attempt to gain that trust and control.  The insurance company would rather deal with a layperson than an attorney. The insurance company knows that an experienced plaintiff's attorney may substantially increase the value of the claim.

The claims adjuster normally will receive a first loss report form from an agent or an insured. This allows the adjuster to gather the names and numbers of the individuals involved so that contact can be made prior to the involvement of an attorney.

The claims adjuster will attempt to determine facts that are favorable to the insurance companies case and facts that may limit coverage or damages.

The insurance adjuster may request statements regarding the incident, including written statements and recorded statements. They may also request information regarding employment, school records, and medical records.  Take caution in providing this information without contacting an experienced Plaintiff’s attorney.

The insurance adjuster will be expected by the insurance company to maintain a claims file. This file typically will contain the information related to the investigation of the claims adjuster. The adjuster may also be put on notice of certain liens, including those filed by hospitals, doctors, and other insurance companies.

The insurance adjuster will typically have a claim’s manual, which educates him or her regarding what it must do to resolve cases.  Sometimes, insurance companies fail to accurately train an adjuster with regard to these manuals.

Helpful Links

Insurance Contracts by Investopedia

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