Most Texans are familiar with the process of purchasing insurance. Once the need for insurance is identified, the person who seeks the insurance contacts an agent who sells the kind of policy (homeowners, automobile, business interruption and the like) and asks for details such as coverage, periodic premium amount, and any exclusions.
Once the details are resolved, the prospective insured pays the initial premium, and the policy becomes valid. At this point, the insured hopes that he or she never needs to revisit the issue of insurance. But on some occasions, a person will purchase an insurance policy and assume that any claims will be promptly paid. But what happens if the insurer refuses to pay the claim?
Some insurance companies have internal appeal processes incorporated into the text of the insurance contract, and this process must be followed before any external appeal may be filed. Most policies do not contain such a provision, and the policy holder’s only option is a lawsuit challenging the legal validity of the insurer’s denial. Before pursuing a court appeal, the policy holder should do several things.
The first is understanding exactly what the company has done and why. The denial letter must clearly state the reasons for the denial of the claim. Some healthcare policies, for example, require a referral for care rendered by a physician who is not part of the insurance company’s network of care givers.
If this information is not contained in the denial letter, an inquiry from a lawyer experienced in insurance coverage may convince the insurer to provide the requested information. The policy may state a deadline for filing a court appeal. Do not let this deadline pass without taking action.
Many insurance claims rely on documentary evidence to prove the basis for the claim. This is especially true for claims under health insurance policies and business interruption claims.