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 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.

What is a common reason a car insurance claim could be denied? ›

Your auto insurance claim will be rejected if you were found violating the law during the accident. Driving without a license, exceeding the speed limit, and driving under the influence (DUI) are some of the most common causes of denial of an insurance claim.

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.

What are five reasons a claim might be denied for payment? ›

Here are some reasons for denied insurance claims:
  • Your claim was filed too late. ...
  • Lack of proper authorization. ...
  • The insurance company lost the claim and it expired. ...
  • Lack of medical necessity. ...
  • Coverage exclusion or exhaustion. ...
  • A pre-existing condition. ...
  • Incorrect coding. ...
  • Lack of progress.
Mar 5, 2013

What are the possible solutions to a denied insurance claim? ›

You can ask your doctor to resubmit the claim and correct the error. If your claim was denied for another reason, let your doctor know that you're appealing a claim. You can ask your doctor to write a letter explaining that the service was medically necessary, or provide other supporting documents.

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

Bad faith insurance refers to an insurer's attempt to renege on its obligations to its clients, either through refusal to pay a policyholder's legitimate claim or investigate and process a policyholder's claim within a reasonable period.

How do I argue an auto insurance claim? ›

Submit a Claims Appeal Letter to the Insurance Company

This letter should explain why you believe the claim was incorrectly denied and include evidence to prove your argument. Evidence you should send with the appeals letter includes photos, videos, medical records, and witness testimony.

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.

Why would an insurer reject a claim? ›

Reasons for this include: not having enough insurance to cover your losses (known as being underinsured) the insurer believes your valuation is unrealistic. the item you want to replace was old and you have already benefited from using it.

What are the 3 most common mistakes on a claim that will cause denials? ›

Here, we discuss the first five most common medical coding and billing mistakes that cause claim denials so you can avoid them in your business:
  • Claim is not specific enough. ...
  • Claim is missing information. ...
  • Claim not filed on time (aka: Timely Filing)

Which clause prevents an insurer from denying a claim? ›

What Is an Incontestability Clause and How Does It Protect You as a Consumer? An incontestability clause in an insurance policy prevents the insurance company from contesting the policy based on errors in the application, outside of a defined contestability period.

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

Some of the most common reasons for claim rejection are as follows:
  • Incorrect Information on the Claim Form. ...
  • Raising Claims During the Waiting Period. ...
  • Non-Disclosure of Pre-existing Diseases. ...
  • Lapsed Health Insurance. ...
  • Delay in Claim Intimation. ...
  • Missing Documents During Claim Submission.

What is a dirty claim? ›

Dirty Claim: The term dirty claim refers to the “claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment”.

Why would my claim be rejected? ›

The main reason why an Insurer denies a claim is due to the Insurer claiming that the Insured did not meet, or does not comply with, the conditions outlined in its policy. Insurance firms rightfully deny thousands of claims every year however plenty of circ*mstances exist where an Insurer has denied a claim.

What to do after a claim is denied? ›

File an appeal

Filing a formal appeal triggers a review of your denied claim. Include with your appeal as much evidence and documentation as you can to support the position that your damages should be covered.

Why are insurance claims rejected? ›

Incorrect information

You might have given incomplete or inaccurate details during your claim, intentionally or by mistake. For example, how something happened or got damaged.

How often are insurance claims denied? ›

In 2021, insurance companies denied on average 17% of in-network claims filed. Claim denials leave people, who pay insurance companies thousands of dollars in premiums to cover their health care costs, with hefty medical bills and medical debt. Yet, almost no patients challenge these denials. But they should.

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