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Top Reasons for Insurance Claims Denials and What You can do After

August 21, 2023

As adults, we prepare for the unexpected by ensuring that our property and health have adequate insurance coverage to repair any damages we suffer. But when our coverage fails us and an insurance claim is denied, it is extremely unsettling and worrisome.  

Let’s consider why this may happen and what steps to take when you encounter the denial of a Charleston, WV, insurance claim.

Error in Paperwork

Paperwork errors are common but simple to correct just by reviewing the paperwork. In healthcare, it may be that the wrong billing code was entered, and when personal property is damaged in an accident, it might be that the incorrect information for a policyholder is entered. Start by rereading the documentation to account for any errors.

A Service or Repair is not Covered or Coverage Amounts Have Been Exceeded

Your auto insurance may not cover the damages your automobile incurs because of the cause of the damage and the coverage you have purchased. Additionally, each individual purchases a certain amount of insurance coverage. Once that amount has been exceeded, you may need to file a personal injury claim in West Virginia if you were in an accident and suffered damages that the at-fault driver’s insurance company refuses to cover.

With health coverage, your insurance company may view a procedure as elective instead of necessary. Becoming familiar with individual coverages is significant and allows an individual to purchase additional insurance if necessary.

Missing Information

Insurance companies will use the documentation provided to determine coverage awards. When critical information is missing, such as a referral from a doctor or a police report detailing an accident, the insurance company may not see supporting evidence to approve your claim.

Failure to Follow Procedures

For healthcare, preauthorization and in-network services are often required to have a procedure approved or covered at the maximum coverage rate. If the procedure is not an emergency, seek approval beforehand and check the list of providers to ensure that the physician is covered in your network.

Time limits also apply for filing a claim. Failure to file a claim within the allotted time can result in a denial. 

Options for Reversing a Claim Denial

Unfortunately, insurance companies aim to minimize the money they pay to protect their profits. This practice may require more diligence on the insured individual’s part to ensure proper payment.

File an Appeal

Insurance companies must respond to claims submissions within a specified time frame. If your claim is denied, follow the established appeals process. Ask for documentation explaining the reason for the denial and request an internal review.

Request an External Review

If you feel the appeals process was unhelpful, then filing an external complaint with the West Virginia Offices of the Insurance Commissioner is an option. 

Work with a Knowledgeable West Virginia Insurance Claims Attorney

As a consumer, you have a right to the insurance services you pay for. Salango Law, PLLC has worked relentlessly for decades to ensure its clients receive fair compensation after a West Virginia insurance claim denial. 

If you feel that you have followed the guidelines put in place by an insurance company, but your claim has been denied, schedule your free West Virginia insurance claims consultation to discuss your claim and better understand how we fight against insurance claims denial.