How to Appeal for Denied Health Insurance Claims

denied health insurance claims los angeles

A health insurance policy is not a guarantee that you will get reimbursed for all your healthcare expenses, or that your hospitalization costs will all be shouldered (whether in part or entirely) by your insurer. Insurance might be marketed as a customer-centric product, but remember that behind these products are companies that must look out for their financial welfare. In all fairness, they also need to vet applications so that only qualified claims will be reimbursed.

What happens if your insurance claim is denied? You can file an appeal if you think the outcome has no basis and is unjust. If all else fails, our bad faith insurance attorney in Los Angeles is only one phone call away; but for now, let’s focus on your appeal.

What to Do If Your Insurance Claim Gets Denied

If your insurer denies your claim, they will send you an official letter stating the reason for the denial and possibly quote clauses in your policy that presumably justifies this decision. Don’t panic or be disheartened right away if you get such a response because you can still file for an appeal.

Here’s what you need to do:

  1. Review the appeal process for your insurance company. It differs for every company. Talk to your agent, and ask whom to address your appeal, what documentation you need to prepare, the deadlines for submitting an appeal, and so forth. The information may be available on their website, but it always helps to discuss it with someone knowledgeable about this process.
  2. Review your policy. Take note of the reason your insurer cited for the denial of your claims. Review the clauses that supposedly invalidates your claim. It’s not yet necessary to consult an attorney at this point, but it would be helpful if you can go through those clauses with people who know how to pick apart the legalese and show the key points of your contract.
  3. Prepare your letter of appeal and supporting documents. It must contain your personal information and insurance details. State the reason cited for your claim’s rejection. Explain why you think the resolution should be the opposite and that your policy covers your recent medical procedure or treatment (this is why it’s advantageous to have an attorney advise you on the details of your insurance policy and how to argue your position). If it supports your claim, include other documents like a letter of medical necessity by your doctor, results from first tests and second opinions. These documents should explain why the treatments you received were necessary for your health condition. Finally, produce and keep copies of your appeal documents in case you need references later.
  4. Submit your appeal documents. You must make sure that your insurer has officially received your appeal, so consider sending the documents via:
  • Fax (you can get a confirmation for a successful transmission)
  • Certified mail (you can request a Return Receipt)
  • Personal delivery (you can note the time, date, and name of the staff who received your appeal documents plus note your delivery at the receptionist’s log)

If your insurer still denies your claim, you may persist with yet another appeal, or you can escalate your response by filing a bad faith insurance claim.

Haffner Law can assist with your filing. We have years and years of experience in dealing with bad faith insurance cases, and we always work our hardest to help our clients get the compensation they deserve.

Contact us via our website and schedule an appointment.

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What to Do if Fire Damage Claim is Denied

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Fires cause severe property and financial losses to businesses, which is why you need fire insurance. However, fire damage claims can get complicated and frustrating. Insurance companies can lower your compensation or reject your claim completely, leaving you with out-of-pocket expenses.

There are various reasons insurance companies deny your claim. Below are some of the most common:

  • Questionable claims or false statements
  • Insufficient documentation of the damage
  • Insufficient evidence
  • Missed premium payments
  • Exclusion clauses in your policy

Regardless of the reason, you have the right to re-appeal and demand a second look into your claim. An experienced property damage insurance attorney can help you build a stronger case and assist you through the appeal process.

Here’s a 3-step guide to filing an appeal for a denied fire damage claim.

  1. Review the denial letter

Your insurance provider will send a letter explaining why they rejected your claim. Compare the reasons they listed with the inclusions of your policy. This can be difficult due to the jargon used in the contract, which is why you need the help of an insurance lawyer.

Check if your policy coverage is enough to cover the loss. If it isn’t, there’s no reason for you to file an appeal.

If you confirm that the insurer’s dismissal of your claim is unreasonable, contact your agent or an insurance adjuster to raise your concern. Document every conversation you have with your insurance company, including the date, time, name of the person you spoke with, and what was agreed upon. 

  1. Strengthen your case

The burden proof is on you, so you have to have a strong, solid case to prove your loss from the fire. You can hire a public adjuster to help you explain the loss in detail and identify the clause in your policy clearly stating that the damage should be covered. Include the following details to strengthen your case:

  • Documentation and proof of the damage (e.g., photos)
  • Detailed evidence of the loss (e.g., financial statements)
  • Efforts to have your case reviewed (e.g., communication log with the insurer)
  • Rebuttal to the insurance company’s denial (e.g., policy information showing the loss should be covered)

If your claim remains unnoticed, climb the command ladder. Try to arrange a meeting or conversation with the insurer’s supervisor, manager, all the way to the director. The process may be laborious and time-consuming, but it will be worth it when you finally receive the compensation, especially if the fire damage was large-scale. 

  1. File a complaint

Your last resort is filing a complaint against the insurance company. This will automatically trigger a review of your denied claim. The insurance commissioner will handle your case and will evaluate your complaint and actions taken to get a second look into your claim.

If you do file a complaint, your insurance company might demand you to attend an Examination Under Oath. This legal process requires the legal counsel and representation of an insurance lawyer.

Aggressive Insurance Attorney in Los Angeles

Haffner Lawyers has a team of experienced insurance attorneys who will assist you throughout the process of your appeal. We take an aggressive approach in all our cases, making sure you have a strong case to support your claim. Our lawyers work to make sure you receive the compensation you deserve, enough to help your business recover from the fire.

For a consultation with a property damage insurance lawyer in Los Angeles, give us a call at 213-514-5681.

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What Do You Do if an Insurance Company Contests Your Claim?

Life Insurance Claim Lawyer Los Angeles

Insurance companies have a right to question, delay, or deny your life insurance claim. Normally, the beneficiaries will receive the payout several weeks following the death of the policyholder. But the insurance company has many reasons to hold or refuse the release of your insurance benefits.

In such a scenario, it’s best to have the legal advice of an experienced life insurance lawyer. They’ll help you defend your claim and make sure that you receive a fair settlement.

Below are the most common circumstances where a lawyer can help you with a contested life insurance claim.

  1. The policy holder died during the contestability period

 Most insurance providers set a contestability period when activating a new policy. Under California law, this period lasts two years, starting from the day of the first payment. This clause gives the insurer the right to investigate the death of the policyholder if it occurred anytime during the contestability period. The insurance company will check if you withheld or misstated any relevant information that may have influenced the death.

One example is if the policyholder failed to indicate that they’re a heavy drinker, then died of liver damage several months following the insurance application. The insurance company can cancel the policy due to insurance fraud.

Insurance misstatements are subjective, which means you have the opportunity to defend your insurance claim. Plus, misstatements should be material. Their nature should be grave enough for the insurer to terminate or alter the insurance agreement. A life insurance lawyer will help you negotiate or fight for your settlement by backing up your claim with the appropriate documents and information.

  1. The policy has lapsed before the policyholder died

 Missed and incomplete payments are common reasons insurance providers refuse to pay out the death benefit. All life insurance policies require a steady payment of premiums to remain active. Otherwise, they’ll lapse. This invalidates your entire claim, even if the policyholder has made payments prior to it lapsing.

However, a missed payment doesn’t automatically deny you of your benefits. The chances of getting a death benefit are higher if the death occurred within 30 days of the policy lapsing.

Your insurance attorney can also investigate if the insurer is in any way responsible for your failure to reinstate your policy. Many states require insurance companies to notify clients before and after they cancel a policy, giving you an opportunity to renew it. If you prove that the insurance company failed to send the necessary notices, you may get the chance to recover the policy.

  1. The death involves unusual circumstances

Many life insurance companies refuse to cover deaths that involve unusual circumstances, such as suicide, homicide, or if the beneficiary is a suspect. Almost every insurance policy involves a clause that exempts coverage for applicants who committed suicide. Some also refuse to pay benefits to policyholders who were intoxicated at the time of their death.

A life insurance attorney will assist you in proving that you’re not complicit to the policyholder’s demise, if ever the case is established as a homicide. A lawyer can also help disprove that the death is due to suicide if necessary.

Defending a contested life insurance claim can get complicated, potentially involving a legal process. This is why you’ll need the experience of a capable attorney who has handled similar cases.

A Capable Lawyer on Your Side

 Our Los Angeles life insurance lawyers will work with you to determine exactly what was wrong with your claim to file a successful appeal. We’ll review your policy together to ensure that your claim falls in line with what you’re owed. Haffner Lawyers will build your claim, support it with strong, concrete evidence, to get you the settlement you deserve.

Contact us at 1-844-HAFFNER (423-3637) to schedule a consultation today.

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Material Misrepresentation and the Risk of Insurance Claim Denial

Life Insurance Claim Denial Los Angeles Lawyer

Voluminous paperwork, hours spent going over the different types of policies, and endless meetings with your insurance agent—sometimes, working with insurance companies can be stressful.

Like any other business insurance companies must also do what they can to turn a profit. And sometimes, the way they do this is by making it difficult for the beneficiaries of policyholders to successfully file for a claim, or by denying insurance claims, outright.

However, an insurance provider cannot legally deny an insurance claim for no reason. And often enough, it is the policyholder’s fault that leads to the denial of an insurance claim. When you fail to supply accurate information during the insurance application process, for instance, your insurance provider may discover it and deny your claim on the grounds of material misrepresentation.

What is Material Misrepresentation?

During the insurance application process, the insurance company will ask you questions about yourself and your lifestyle. The questions range from the typical name, age, and birth date to your family’s medical history.

Cases of heart disease and cancer within your family, as well as your history of alcohol and tobacco use, are all health-related information that affects your insurance rates. If your family has a history of hereditary disease, for example, you may have to pay higher premiums because you have a higher possibility of succumbing to those diseases than an applicant who has a better family medical history.

This fact might push some applicants not to disclose their real family medical history. Some omit previous cases of hospitalization or outright lie about family members having hereditary diseases just so they could avoid paying higher premiums. This is called material misrepresentation.

However, it is advisable that you disclose only accurate information during the application process. When you have been approved of a life insurance policy, your policy will enter into a two-year contestability period in the state of California. This means that for two years after you paid your first premium, your insurance provider will be investigating the truthfulness of the information you provided. If they obtain proof that contradicts what you said, your policy might be forfeited.

Keep in mind, though, that minor mistakes, such as the street name on your address or your surname, will not be deemed as material misrepresentation. It is only “material” if the inaccurate information you provided is important enough that, had the insurer known about it from the outset, it would have resulted in a fundamentally different insurance policy, with different premiums.

In addition, some insurance providers may still approve insurance claims despite cases of material misrepresentation. However, you should not count on this. Always ensure that the information you provide when you apply for a life insurance policy is correct and factual, to avoid complications down the road.

What Do You Do If Your Insurance Claim Gets Denied Due to Misrepresentation?

Enlisting the help of a qualified life insurance attorney is the best move you can make if your insurance provider in Los Angeles denies your claim based on material misrepresentation. At Haffner Law, our insurance lawyers can give you legal assistance, especially if you have been wrongfully denied an insurance claim. With our help, you can have your life insurance policy restored and be compensated for other damages.

Get in touch with us today. Contact 1-844-HAFFNER for a free consultation.

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