Why Insurance Companies Deny Accident Claims - Whale Law (2024)

You always do the right thing when making decisions, right? You are always fair minded and generous to people who are less powerful and in a vulnerable position, right? People are generally decent, right? Why is it, then, that insurance companies employing otherwise reasonable, fair-minded people do not give fair-minded value to the claims of innocent victims? This article reveals five reasons why systematic undervaluing of insurance cases occurs.

  1. A MONEY MAKING ENTERPRISE

An overlooked motivating factor for low payouts on injury cases is our capitalist system for the insurance company. Corporations are entities, even referred to at times as “persons.” Insurance company corporations have one goal above all others: to make the maximum amount of money for their owners. Their owners are (typically) stock owners who pay money for stock shares and expect more money in return by way of dividends or increased stock value. From the executive desk of the president down to common employees, this money motivating factor colors all decisions of businesses. Insurance companies are no exception.

Insurance companies make money by charging their customers premiums. They also make money from investing the money that is given to them and making dividends or profits on that money. Insurers maximize profit by minimizing their expenses. Paying money for insurance claims is a large expense of an insurance company. The less that is paid out, the more money for their owners (the stockholders).

Insurance companies will deny paying more in payouts when the investment market is expected to do a down turn versus when money is to be made. However, in our experience, insurance companies do pay out differently for tax reasons, market force reasons, and investment timing. One way or the other, capitalism, money, and timing influence the fair value by which insurers assess to your case.

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  1. INSURER DELAY MEANS INSURER MONEY

You may notice the larger the insurance claim, the more time, procrastination, and delay the victim will experience. This is no coincidence. Remember, insurance companies do not handle just your claim. Insurers handle tens or thousands of claims at any one time. With any large population, emergencies for some claimants will occur. Financial troubles will crop up for some claimants. Some claimants merely drop out because of exhaustion. This means that the longer an insurance company can delay a claim, the more people will drop out for various reasons that are personal to each person.

Even claimants that do not drop out, may take less than the full value of their case for similar personal reasons. Some people merely get into a situation where they are desperate for money and will take whatever is offered. The longer the delay, the more likely this is.

We talked in reason number one (above) about how insurers make money from investments. Remember, the longer the delay in paying you, the more time the insurance company has to invest the money that the insurer would have otherwise given you. Simply put, delay pays.

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  1. THE DIFFUSION OFRESPONSIBILITY

We all feel guilt and negative emotions over decisions which harm others. Nobody wants to be the “bad guy.” We all like to point to the other person and saytheyare the “bad guy.” Others will say they simply were one piece in the cog of a big machine and did not make the final decision. This diffusion of responsibility is the genesis of many injustices perpetrated by insurance companies.

Remember, it is often the case that insurance claims are handled by many people. If not just one person makes a bad decision; it is a group decision. Guilt is diffused and can be blamed on others. The executive office can order managers who can then blame the executives. The managers can order employees who can then blame the managers. Employees are large in number and can blame each other. One way or the other, if no one person is at fault, no one person bears all the guilt. This diffusion of responsibility is one way in which innocent victims with the insurance claims suffer further injustice through an unfair evaluation or a complete failure to pay a rightful claim.

Natural Selection in favor of Unfair Insurance Employees

Please also note there is a natural selection issue with respect to insurance companies. Each employee will have employment responsibilities and guidelines. It is often the case that an employee gets better evaluations and a superior work relationship when the employee makes more money for their corporation.

Employees that lose money for their company tend to be fired. In an insurance situation, this means the less money is paid out to otherwise rightful claims; the more money the insurance company makes; the better the employee is viewed. I have personally seen this attitude in my insurance adjuster acquaintances. These are people that are otherwise good, well meaning, and have the victim in mind. They simply get overwhelmed by the money and the desire to please their bosses.

  1. A DIFFERENCE IN VALUE OPINIONS

We all value our own family, our own friends, our own possessions and pets more than other people value them. Each of us has a personal affinity for the things closest to us. This creates a natural bias when those things are lost. The death of your own pet is more important to you than the death of a stranger’s pet.

So too is it true with injury accident claims. Your pain, your suffering, the accident’s effect on your life is more meaningful and valuable to you than a stranger. This results in claims adjusters at insurance companies who simply don’t share your value for your suffering as a victim. Therefore, insurance offers are made valuing an average payout rather than your particular experience.

Computers Affect Accident Claim Value

Computers are also the enemy of value! Many insurance companies have specific proprietary programs, such as Colossus, originally made for Insurance. These computer programs place values on many claims. Like all computer programs, they make mistakes and are imperfect. Insurance claim computers may simply fail to take into account all your particular circ*mstances. Remember, these computers were built and paid for to save insurance companies money. Their primary goal was not justice for an accident victim.

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  1. TOO FEW VALUE HEROES

Full value of case is often reached only after attorneys are hired, litigation is handled, a jury trial ensues, and a decision is given. Sometimes there is even an appeal! With so few people taking the full journey, accident claim values overall go down. This means even the few people that do go the distance see higher costs and less money in the end because they must make the added effort to “blaze the trail.”

It is understandable to identify with the people who take the money for less than full value. We all have stress in our lives. Few are highly experienced at insurance injury claims. We all want the pride of handling a claim ourselves. Unfortunately, this also tends to result in lower values for the claim. So many drop outs create a bias on the part of those who pay the claims (the insurance companies and lawyers). Insurers get accustomed to their own victories. The failure of large numbers of people forcing full accident claim values creates an average value payout that is less than reasonable.

I hope these five reasons have informed you. Others exist. None of them are equally important. However, remember that your decisions will also affect the justice that others will receive in the future. Good luck!

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Trial lawyer Matt Hamilton graduated from the University of Missouri – Columbia in 1995 with Science degrees in Logistics, Marketing, and Business Administration.

Matthew J. Hamilton
Juris Doctor & Crypto Lawyer

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Why Insurance Companies Deny Accident Claims - Whale Law (2024)

FAQs

Why do insurance companies always deny claims? ›

Insurance companies deny claims for many reasons, such as insufficient evidence, missed deadlines, or policy exclusions. If your insurance company denied your claim, you can file an appeal, agree to mediation or arbitration, or take the insurance company to court for bad faith.

Which of the following is a reason that an insurance claim may be denied? ›

The claim has missing or incorrect information.

Whether by accident or intentionally, medical billing and coding errors are common reasons that claims are rejected or denied. Information may be incorrect, incomplete or missing. You will need to check your billing statement and EOB very carefully.

Why do insurance companies ignore claims? ›

Insurance companies make money by not paying claims.

If they can ignore you and pay you less, it means more profits in their pockets at the end of the day, helping their bottom line. The longer insurers don't pay your claim, the more interest they can make off of the money you may be entitled to.

How do I deal with a rejected insurance claim? ›

You can start the appeal process by calling your insurance provider. Ask for more details about the denial and review your appeal options. Your insurance agent can walk you through the appeals process to help get you started.

How often do insurance companies reject claims? ›

According to the Medical Billing Advocates of America, across the healthcare industry 1 in 7 claims is denied, often for a variety of reasons ranging from technical errors to simple administrative mistakes.

What happens after a claim is denied? ›

You may be able to appeal to your insurance company multiple times based on the evidence you provide. If the outcome is not satisfactory, you can consider contacting a public adjuster to advocate on your behalf or file a complaint with your state's insurance department to act as an intermediary for the dispute.

Which of these would be a valid reason for a claim to be denied? ›

A fraudulent claim happens if a policyholder provides false information while filing for a claim to gain more coverage from their insurance plans. On verification, this act can lead to not only the claim being rejected but also into legal action for the individual who filed a fraudulent/false claim.

Why would an insurer reject a claim? ›

You have missed some of the instalments of your premium. You have not followed the claims process correctly. You have not complied with a policy term. You have exaggerated the claim and are trying to claim for more than you should.

What is it called when a claim is denied? ›

Denial of claim is the refusal of an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.

Why does my insurance company keep denying my MRI? ›

While it is unlikely that your insurer would deny your claim for an MRI scan by saying the procedure is experimental, it may claim the scan is “not medically necessary.” The insurance company may require your physician to first perform x-rays and a CT scan to determine the cause of your medical issue because those ...

Why are most insurance claims denied? ›

Insurance claims are often denied if there is a dispute as to fault or liability. Companies will only agree to pay you if there's clear evidence to show that their policyholder is to blame for your injuries. If there is any indication that their policyholder isn't responsible the insurer will deny your claim.

Can you sue an insurance company for ignoring you? ›

Takeaway 2: The legal term for this action is a “bad faith lawsuit”, which claims that the insurer has not met its obligations to act in good faith and fair dealing. Takeaway 3: To win such a case, you must prove that the insurance company had no reasonable basis to deny your claim or delay payments.

Why do insurance companies drag out claims? ›

Why Do Insurers Drag Their Feet in Handling Your Claim? Since insurance companies take the money they receive from premiums and invest it, the longer they keep those funds, the more interest they earn. This gives them a significant incentive to delay paying out on claims as long as possible.

Why does State Farm deny so many claims? ›

It's important to know some of the reasons State Farm will deny claims. They might claim that you missed a payment, have lapsed coverage, insufficient evidence, lack of medical records, lack of witnesses, that you had a previous injury, that you really aren't that hurt, etc.

What is it called when an insurance company refuses to pay a claim? ›

Bad faith insurance refers to the tactics insurance companies employ to avoid their contractual obligations to their policyholders. Examples of insurers acting in bad faith include misrepresentation of contract terms and language and nondisclosure of policy provisions, exclusions, and terms to avoid paying claims.

Can an insurer refuse a claim? ›

If your claim has been refused because of a condition or exclusion, you might be able to argue: the insurer was wrong in applying the condition or exclusion. the condition or exclusion did not cause the loss (or only part of it) or the insurer wasn't disadvantaged by it (s54 of the Insurance Contracts Act)

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