After an injury, you may expect the insurance company to investigate what happened, review your medical bills and other losses, and pay what you are owed. Instead, you may receive a denial letter, or an adjuster may tell you that the company does not believe it is responsible for your injuries.
A denial does not necessarily mean you have no legal options. Insurance companies make mistakes, dispute liability, challenge the severity of injuries, and rely on policy exclusions or other defenses when evaluating claims. If your injury claim has been denied, attorney Javier Guzman and the legal team at Guzman Law Firm can review the denial, the evidence supporting your claim, and the circumstances surrounding your injury to determine the best path forward.
If you’re wondering what to do if the insurance company denies your injury claim, call us today at (956) 516-7198 for a free case review.
Can insurance deny an injury claim?
Yes. An insurance company can deny an injury claim when it has a legally or contractually recognized reason for doing so. However, an insurer cannot simply deny a claim without justification or ignore evidence that supports coverage or liability.
The reason for a denial matters. If an insurer says the accident was your fault, for example, the evidence concerning how the accident happened becomes important. If the insurer argues that your injuries were caused by a pre-existing condition, your medical records and evidence connecting the injury to the accident may become critical.
For claims made under your own insurance policy, Texas law generally requires an insurer to explain a denial in writing. The Texas Department of Insurance also states that insurers cannot refuse to pay a claim without conducting a reasonable investigation.
Why do insurance companies deny claims?
Insurance companies may deny injury claims for several different reasons, including:
- Disputing who was at fault. The insurer may argue that its policyholder did not cause the accident or that another person was responsible.
- Questioning the cause of your injuries. An insurer may argue that your injuries existed before the accident or were unrelated to it.
- Disputing the severity of your injuries. The insurance company may claim that your treatment was unnecessary or that your injuries are not as serious as reported (whiplash, for example, may not become apparent until days after you reported your accident to the insurer).
- Policy exclusions or coverage disputes. Your insurer may argue that the particular circumstances of the accident are not covered under your policy.
- Insufficient documentation. Missing medical records, accident reports, photographs, witness information, bills, or other evidence can make a claim more difficult to establish.
- Disputing the value of the claim. Sometimes the dispute is not whether you were injured, but how much compensation your injuries justify.
A denial letter should tell you why the insurance company rejected the claim. That explanation can help identify what evidence or legal issues need to be addressed.
How long do insurance companies have to accept or deny a claim?
For many first-party claims (e.g., claims you make against your own insurance policy), Texas law establishes specific claim-handling deadlines. Generally, an insurer must acknowledge receipt of the claim within 15 days and, after receiving the information reasonably needed to evaluate it, must accept or deny the claim within 15 business days. The insurer can extend the decision deadline by up to 45 additional days if it provides the required notice explaining the delay.
If the insurer approves the claim, Texas law generally requires payment within five business days after the insurer gives notice that it will pay.
There is an important distinction for third-party injury claims. If you were injured because someone else was negligent and you are seeking compensation from that person’s liability insurer, the first-party prompt-payment deadlines do not necessarily apply in the same way. The Texas Department of Insurance notes that when another driver’s insurance company is handling the claim, the insurer still must act in good faith and attempt to settle the claim fairly and promptly.
How to fight a denied insurance claim
1. Start by getting the denial in writing if you do not already have it.
Identify the precise reason the insurance company gives for refusing the claim. Then gather the evidence that addresses that reason. Depending on the circumstances, that may include:
- The accident or incident report
- Photographs or video of the accident scene
- Witness statements and contact information
- Medical records and bills
- Diagnostic imaging and physician opinions
- Documentation of missed work and lost income
- Evidence of your physical limitations or ongoing treatment
- Insurance policy documents
- Communications with the insurance adjuster
- Estimates, receipts, or other documentation of financial losses
2. Do not assume that the adjuster’s conclusion is the final word.
An adjuster is evaluating your claim for the insurance company. If the insurer’s investigation overlooked important evidence, misunderstood the circumstances, or reached a conclusion that is inconsistent with the available evidence, the denial may be challengeable.
3. Keep records of every communication with the insurance company.
Save letters, emails, claim documents, photographs, estimates, and medical records. Write down the dates of significant phone calls and what was discussed.
Can you sue an insurance company for denying a claim?
Sometimes, yes; but a denied claim does not automatically mean you have a lawsuit against the insurance company. The potential legal claims depend heavily on which insurance policy is involved, why the claim was denied, the terms of the policy, and how the insurer handled the investigation.
Texas law prohibits certain unfair claim-settlement practices, including failing to conduct a reasonable investigation, failing to attempt a prompt and fair settlement when liability has become reasonably clear, and other prohibited conduct in the handling of claims.
In some circumstances, an insured may have remedies under Texas insurance law when an insurer improperly handles or denies a covered claim. There can also be contractual claims concerning the policy itself.
But suing an insurer is not as simple as filing a lawsuit because the company said no. The evidence has to establish the underlying claim and support whatever legal theory is being pursued. An attorney can evaluate the denial before you commit to litigation.
When legal representation becomes necessary
You do not necessarily need an attorney for every insurance claim. Some straightforward claims can be resolved by providing additional documentation or correcting an administrative mistake. Legal representation becomes particularly important when:
- The insurer has formally denied your claim.
- The insurer disputes who caused the accident.
- The insurance company blames you for your injuries.
- Your injuries are serious or permanent.
- You have substantial medical expenses or lost income.
- The insurer argues your injuries were pre-existing.
- Multiple insurance policies may apply.
- The insurer is pressuring you to accept a settlement quickly.
- The company refuses to reconsider despite evidence supporting your claim.
- You believe the insurer failed to properly investigate your claim.
A Laredo personal injury lawyer can also help protect you from making statements or accepting a settlement before you understand the full value and legal implications of your claim.
For serious injuries, waiting too long can create additional problems. Evidence can disappear, witnesses can become difficult to locate, medical documentation can become harder to organize, and legal deadlines can limit your ability to pursue a claim.
If an insurance company has denied your injury claim, do not assume the denial ends the matter. Have the denial and supporting evidence reviewed before giving up on compensation you may be legally entitled to pursue.
Injured by another’s negligence? Don’t get left holding the bag. Call Guzman.
You should not have to carry the financial burden of an injury caused by someone else’s negligence simply because an insurance company refuses to pay. Knowing what to do if the insurance company denies your injury claim can make all the difference in how you may be compensated for your injuries.
Javier Guzman and his team at Guzman Law Firm can investigate what happened, examine the insurance company’s position, gather evidence supporting your claim, and pursue the compensation available under Texas law.
If your injury claim has been denied, do not let the denial be the last word. Call Guzman Law Firm at (956) 516-7198 to discuss your options.
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