Deny, deny, deny…this is not just a scene from "A Guide for the Married Man" or a title of a popular episode from Grey's Anatomy; it is also a tactic that insurance companies turn to, when they are trying not to pay a claim. There are actually many deny tactics that insurance companies use, but some of the most popular reasons for denial are (1) fault of the claimant, (2) conflicting versions of the facts, (3) failure to timely report the claim, (4) gap in treatment, and (5) low impact between the vehicles, in a car accident.
1. It was your fault!
Fault of the claimant (injured party) is the number one reason that claims are denied. I would expect that this reason for denial is not too surprising, for most. If all of the evidence points to the claimant, the person making the claim, as the one that caused the incident, it would be natural to expect the insurance carrier to deny liability on the claim (refuse to pay). I am not saying that, in every instance, where a driver is found to be at fault, in a car accident, that the liability determination cannot be changed. New evidence can be presented to the investigating officer that could change his/her fault determination. The claimant could also present that new information to the insurance adjuster and he/she could definitely change the liability determination. I had a case, where a client was found at fault, initially, but he walked up and down the street, where the motorcycle accident happened, and found a house that had a Ring Video Doorbell and it actually caught the motorcycle accident and once presented with the video evidence, the investigating officer and adjuster changed their fault determinations.
2. He said, she said
Disputed versions of the facts is the second most common reason that claims are denied. The less evidence the claimant has, to prove they are not at fault, the more likely it is the claim will be denied. Where there are no witnesses, no videos, no police report…nothing, besides the statements of those involved in the car accident or slip and fall incident, it is rare that an adjuster will side with the claimant, as opposed to their own insured. The adjuster actually owes their insured a duty of good faith and fair dealing and if the claimant cannot provide any evidence, besides their own statement, refuting the insured's version of the facts, the adjuster will almost always uphold that duty, find for their insured, and deny the claim. This is why you ALWAYS want to call the police if you are in a car accident. You ALWAYS want to get witness information and photographic evidence, if you are involved in a slip and fall accident. For any accident, where a witness called the police, you always want to request copies of the 911 calls and present those witness statements, as evidence to the adjuster.
3. Untimely reporting
Untimely reporting is a very technical reason to deny a claim. It is also policy language driven. Some of the issues the court looks at to determine if a denial for untimely filing will be upheld include the language in the policy, will the insurance company be prejudiced if the denial is overturned, and what steps, if any, were taken to report the claim, in a timely manner. If a claimant, or injured party, reports a claim to an insured, in a timely manner, but the insured fails to report the claim to the insurance company, in a timely manner, the carrier has the right to deny the claim for untimely filing; this is why it is so important to know the statute of limitations for the claim and sue the insured, if necessary, to try to protect against this type of denial. Typically, the insured must report the claim to the insurance carrier "as soon as practicable" after the claimant contacts the insured. This is to make sure that all parties know of the claim and all parties are taking the required steps to take care of the claim.
4. Gap in treatment
A gap in treatment can lead to denial of the bodily injury portion of the claim. This can occur even if liability was accepted and property damage was paid for by the insurance carrier. If there is an extended period of time, between the accident that causes the injuries, and treatment of the injuries (gap in care), the adjuster may deny the bodily injury claim; the magic number here seems to be two weeks or more. Besides gaps from date of injury and initial date of treatment, there can also be gaps of time, while treatment is going on. Any gap of treatment, over two weeks, will be of significant concern. Adjusters say that either (1) the injured party could not have been hurt that bad, or they would have sought additional treatment sooner or (2) there must have been another injury (intervening cause) to require the injured party to return for additional treatment, so this new treatment cannot be related to the initial injury. There can be unforeseen circumstances, leading to a gap in care, that could be accepted by the adjuster, like a worldwide pandemic, death in the family or another medical condition, like pregnancy or cancer. Side note, on the gap in treatment, not only does it effect your claim, it also effects and slows down the healing process, so if you are injured, you will want to do your best to avoid any gaps in treatment.
5. Low impact
Denial of an injury claim, specifically a car accident claim, for low impact is a common denial and often difficult, but not impossible, to overcome. There is no set dollar amount, that will bring along the dreaded "low impact" denial, but in my experience, $1,000.00 seems to be in the magic number range. This means that some adjusters like to say, "The property damage was not even $1,000.00; there is no way the person in that vehicle could have been injured." Another common phrase that adjusters like to throw in there, when they are talking about low impact, is mechanism of injury. The impact was so minor, it could not have been the "mechanism of injury" that caused the car accident victim to sustain injuries and suffer. I once had a case, where my client was driving a very old, very sturdy truck and there was literally no visible property damage, but he ended up having to have burr holes drilled in to his skull, to relieve the pressure on his brain, caused from the impact of the collision.
Sadly, there are adjusters that will do all that they can to deny or minimize the value of an accident injury claim. Adjusters may use any of these denials, or a list of others, to try to keep the insurance company from paying on the claim of an accident victim. The accident victim needs to prepare themselves for these potential denials and have valid responses for each, if applicable, to keep their claim from being denied and to receive the compensation they justly deserve.