{"id":352595,"date":"2017-06-13T13:23:32","date_gmt":"2017-06-13T18:23:32","guid":{"rendered":"https:\/\/content.findlaw-admin.com\/ability-law\/consumer\/insurance\/insurance-claims.html"},"modified":"2024-03-29T14:48:37","modified_gmt":"2024-03-29T19:48:37","slug":"insurance-claims","status":"publish","type":"page","link":"https:\/\/www.findlaw.com\/consumer\/insurance\/insurance-claims.html","title":{"rendered":"Insurance Claims"},"content":{"rendered":"\n<div class=\"wp-container-core-columns-is-layout-9d6595d7 fl-sectionWithSidebar fl-container fl-flex fl-flex-wrap fl-gap30\">\n    \n    <div class=\"fl-page-articles fl-section-main fl-section-main-full-width\">\n        <h1 class=\"fl-no-margin-top\">Insurance Claims<\/h1>\n<section class=\"fl-gutenberg-byline\">\n    <div class=\"fl-gutenberg-byline-content\">\n                    By <a href=\"https:\/\/www.findlaw.com\/company\/our-team\/oni-harton-j-d\/\">Oni Harton, J.D.<\/a> | Legally reviewed by <a\n                href=\"https:\/\/www.findlaw.com\/company\/our-team\/melissa-bender-esq\/\">Melissa Bender, Esq.<\/a>\n                | Last updated\n        <time>\n                            March 29, 2024\n                    <\/time>\n    <\/div>\n\n    \n    <details class=\"fl-gutenberg-byline-toggle fl-gutenberg-byline-legally-reviewed\">\n        <summary>\n            <i class=\"fl-gutenberg-byline-icon\" aria-hidden=\"true\"><\/i>\n            Legally Reviewed\n        <\/summary>\n\n        <div class=\"fl-gutenberg-byline-toggle-content\">\n            <p><em>This article has been written and reviewed for legal accuracy, clarity, and style by <a href=\"https:\/\/www.findlaw.com\/company\/our-team.html\">FindLaw\u2019s team of legal writers and attorneys<\/a> and in accordance with <a href=\"https:\/\/www.findlaw.com\/company\/company-history\/editorial-policy.html\">our editorial standards<\/a>.<\/em><\/p>\n\n        <\/div>\n    <\/details>\n\n    <details class=\"fl-gutenberg-byline-toggle fl-gutenberg-byline-fast-checked\">\n        <summary>\n            <i class=\"fl-gutenberg-byline-icon\" aria-hidden=\"true\"><\/i>\n            Fact-Checked\n        <\/summary>\n\n        <div class=\"fl-gutenberg-byline-toggle-content\">\n            <p><em>The last updated date refers to the last time this article was reviewed by FindLaw or one of our <a href=\"https:\/\/www.findlaw.com\/company\/our-team\/contributing-authors.html\">contributing authors<\/a>. We make every effort to keep our articles updated. For information regarding a specific legal issue affecting you, please <a href=\"https:\/\/lawyers.findlaw.com\/?fli=bylinelink\" target=\"_blank\" rel=\"noopener\">contact an attorney in your area<\/a>.<\/em><\/p>\n\n        <\/div>\n    <\/details>\n<\/section>\n<p>You contact an insurance agent, undergo the underwriting process, and pay insurance premiums year after year. No one wants to have to make an insurance claim. It means that you have experienced loss. Each day, people file:<\/p>\r\n<ul>\r\n<li>Health insurance claims<\/li>\r\n<li>Auto insurance claims<\/li>\r\n<li>Life insurance claims<\/li>\r\n<li>Homeowners insurance claims<\/li>\r\n<\/ul>\r\n<p>Before starting the insurance claim process, it&#8217;s important to remember that an insurance claim may take some time to resolve. Understanding how a typical insurance claim proceeds can help you trust the process. It also allows you to know when to get legal advice regarding an insurance claim.<\/p>\r\n<p>FindLaw&#8217;s Insurance Claims section covers the basics of insurance claims, including the process for appealing a denied claim, how to sue an insurer for acting in bad faith, whether you need an attorney to help protect your rights,&nbsp;and much&nbsp;more.<\/p>\r\n<h2>Insurance Claim Process<\/h2>\r\n<p>The insurance claims process differs&nbsp;from one&nbsp;<a href=\"https:\/\/www.findlaw.com\/injury\/accident-injury-law\/liability-for-injury-insurance-options.html\">type of insurance<\/a>&nbsp;to the next. This is the case whether discussing car insurance, home insurance, life insurance, renter&#8217;s insurance, or healthcare insurance. There are common characteristics, though.<\/p>\r\n<h2>1. Sustaining&nbsp;a Loss<\/h2>\r\n<p>The insurance claims process begins when the policyholder suffers a loss. These losses can include the following:<\/p>\r\n<ul>\r\n<li>Damaged property through a natural disaster or&nbsp;<a href=\"https:\/\/www.findlaw.com\/realestate\/owning-a-home\/top-ten-tips-for-filing-fire-insurance-claims.html\">caused by a fire<\/a><\/li>\r\n<li>Injury<\/li>\r\n<li>Illness<\/li>\r\n<li>The death of a loved one<\/li>\r\n<li>A lawsuit<\/li>\r\n<\/ul>\r\n<p>Losses can occur as a result of any number of incidents or events.<\/p>\r\n<h3>2. Reporting the Incident and Making a Claim<\/h3>\r\n<p>Someone needs to notify the insurance company about a loss. Most of the time, this will be the policyholder. There are instances where this is not possible,&nbsp;such as when&nbsp;a beneficiary or other family member notifies the life insurance company through a formal request for a death benefit.&nbsp;<\/p>\r\n<p>In the case of&nbsp;<a href=\"https:\/\/www.findlaw.com\/injury\/workers-compensation.html\">workers&#8217; compensation<\/a>&nbsp;when you are injured on the job, the process has its own set of rules.<\/p>\r\n<p>When you are in an accident or experience a loss, one of your&nbsp;first steps&nbsp;should be&nbsp;to inform&nbsp;your insurance company. Depending on the type of incident, you may also want to file a police report. This is a necessity&nbsp;if you were in a&nbsp;<a href=\"https:\/\/www.findlaw.com\/injury\/accident-injury-law\/insurance-claims-after-an-accident-the-basics.html\">car accident<\/a>&nbsp;or suffered a loss due to theft, burglary, or fire.<\/p>\r\n<p>It&#8217;s critical to contact your insurance company as soon as possible. You have a limited period to report the incident to be eligible for reimbursement. Review your policy to understand applicable time limits. Otherwise, you may risk losing your right to file a claim.<\/p>\r\n<h3>Reporting an Automobile Accident<\/h3>\r\n<p>There may be circumstances where the relative fault of those involved in a car accident determines which insurance company you must contact. For example, if you were in a car accident that was entirely your fault, you&#8217;ll want to contact your insurance agency.<\/p>\r\n<p>Contact the other person&#8217;s insurance company if another driver hit you and was&nbsp;at fault. It&#8217;s important to obtain contact information for those involved in an accident, including any witnesses.<\/p>\r\n<p>If fault is shared, or it&#8217;s unclear who was at fault, it&#8217;s a good idea to contact an attorney first to explore your options and protect your interests. Your attorney will help determine if there&#8217;s a third-party insurance carrier to contact. They can help you every step of the way.<\/p>\r\n<h2>3. Investigating by the Insurance Company<\/h2>\r\n<p>After the insurer receives a formal complaint or claim form, the insurer investigates the claim. The insurer must confirm the claim&#8217;s legitimacy and determine the payout amount. Specific claims may be automatic. Routine claims can occur when you fill a prescription or visit your doctor.<\/p>\r\n<p>Other claims operate in their own way. For example, the insured must take the initiative and file a claim concerning&nbsp;<a href=\"https:\/\/www.findlaw.com\/injury\/accident-injury-law\/insurance-claims-after-an-accident-the-basics.html\">car accidents<\/a>&nbsp;or property damage. The insured may be required to pay a deductible before coverage begins to pay.<\/p>\r\n<h2>Insurance Claims Adjusters<\/h2>\r\n<p>Once your insurance company receives a claim, it appoints&nbsp;<a href=\"https:\/\/dictionary.findlaw.com\/definition\/insurance-adjuster.html\" target=\"_blank\" rel=\"noopener\">an insurance adjuster<\/a>. The role of an insurance adjuster is to:<\/p>\r\n<ul>\r\n<li>Investigate the claim<\/li>\r\n<li>Determine the amount of loss suffered<\/li>\r\n<li>Determine if you are eligible for payment under your policy<\/li>\r\n<\/ul>\r\n<p>The insurance adjuster assigned to your case will commence an investigation. The adjuster will want to interview you about how the accident occurred.<\/p>\r\n<p>Keep in mind that it&#8217;s normal for&nbsp;this conversation&nbsp;to&nbsp;be recorded. Under certain circumstances, you should speak with an attorney before giving a statement to an insurance company.<\/p>\r\n<p>Your adjuster may also interview witnesses and want to review photographs and other relevant documents, such as police reports. Be sure to retain copies of any pictures or other important documents.<\/p>\r\n<p>If the claim involves your homeowners&#8217; policy for damage to your home, the adjuster may visit your home. The adjuster assesses the damage to determine the actual cash value or replacement costs. In some home damage cases, you may get an advance toward the total amount your insurance provider will pay out for personal property recovery&nbsp;or&nbsp;immediate repairs.<\/p>\r\n<p>It&#8217;s a good idea to keep in contact with&nbsp;your insurance adjuster&nbsp;during the process. Respond to all requests and follow up to appraise your claim&#8217;s status. Keep in mind&nbsp;that your appraiser works on several claims at once. The claim process may move slower than you wish.<\/p>\r\n<h2>4. Resolving the Claim<\/h2>\r\n<p>Once the insurance adjuster has completed the investigation, they will resolve your claim by either:<\/p>\r\n<ul>\r\n<li>Approving your claim and giving you payment in full<\/li>\r\n<li>Approving your claim but only giving partial payment<\/li>\r\n<li><a href=\"https:\/\/www.findlaw.com\/injury\/accident-injury-law\/what-to-do-if-your-car-insurance-claim-is-denied.html\">Denying your claim<\/a><\/li>\r\n<\/ul>\r\n<h3>Approving Your Claim in Full<\/h3>\r\n<p>If your insurer pays your claim in full, you&#8217;ll be made whole again. The insurance claim process is complete. You must sign a release stating that if you accept a claim payment, you won&#8217;t be able to bring another claim or lawsuit in the future based on the same circumstances.<\/p>\r\n<h3>Partially Approving Your Claim<\/h3>\r\n<p>When the amount of damage you sustained exceeds the limits of your policy, or some element of your claim is outside of the scope of your policy, your insurance company may only reimburse you in part. Partial approval may occur for the following reasons:<\/p>\r\n<ul>\r\n<li>You did not file your claim within the period specified in your policy<\/li>\r\n<li>You failed to submit to a medical exam<\/li>\r\n<li>Your particular policy did not cover the accident or incident in question<\/li>\r\n<\/ul>\r\n<p>For various reasons, your insurance company may deny your claim altogether.<\/p>\r\n<h3>Claim Denial<\/h3>\r\n<p>The insurer may deny the claim. Reasons to deny a claim could include&nbsp;that the claim isn&#8217;t covered or the insurer determines the claim is not legitimate. The policyholder&nbsp;has an opportunity to appeal the denial.<\/p>\r\n<p>The appeals procedure differs&nbsp;depending on the insurance company. Review your policy carefully to be sure you&nbsp;comply in full with&nbsp;the appeals process.<\/p>\r\n<h2>Insurance Bad Faith and Other Claims<\/h2>\r\n<p>Insurers must follow through on their contractual obligations. The insurance agreement outlines the parties&#8217; obligations. The insurer may be liable for a legal claim when the insurer:<\/p>\r\n<ul>\r\n<li>Fails to cover something that should be covered<\/li>\r\n<li>Fails to pay the total amount<\/li>\r\n<li>Otherwise reneges on its end of the agreement<\/li>\r\n<\/ul>\r\n<p>The legal claim would take the form of an insurance&nbsp;<a href=\"https:\/\/www.findlaw.com\/consumer\/insurance\/how-to-file-a-bad-faith-insurance-claim.html\">bad faith insurance claim<\/a>&nbsp;against the insurer for violating its duty of good faith and fair dealing.<\/p>\r\n<p>Insured individuals may also pursue breach of contract claims when the insurer explicitly violates the contract terms. There is substantial overlap between bad faith claims and breach of contract claims.<\/p>\r\n<p>Other causes of action may include:<\/p>\r\n<ul>\r\n<li>Violations of fraud statutes<\/li>\r\n<li>Violations of insurance codes<\/li>\r\n<li>Estoppel (reliance on the words or conduct of an individual rather than a written agreement) for an agent&#8217;s misrepresentation of coverage<\/li>\r\n<\/ul>\r\n<p>It always pays to understand your rights and obligations as a consumer concerning insurance claims.<\/p>\r\n<h2>Get Legal Help With an Insurance Claim<\/h2>\r\n<p>Insurance claims can&nbsp;go according to plan, but sometimes they don&#8217;t. You should speak with an attorney if you are experiencing issues with an insurance claim or have questions about the process. Contact an&nbsp;<a href=\"https:\/\/lawyers.findlaw.com\/insurance-law\/-law?fli=dcta\" target=\"_blank\" rel=\"noopener\">insurance law lawyer<\/a>&nbsp;to learn more.<\/p>\r\n<div class=\"was-this-helpful\">\n    <div\n            class=\"was-this-helpful__question-container\"\n            aria-labelledby=\"was-this-helpful__question\"\n            role=\"group\"\n    >\n        <span\n                id=\"was-this-helpful__question\"\n                class=\"was-this-helpful__question fl-text-lg-bold\"\n        >Was this helpful?<\/span>\n        <button\n                class=\"was-this-helpful__button fl-text-sm\"\n                aria-label=\"Yes\"\n                value=\"yes\"\n        >\n            <span class=\"was-this-helpful__button-text fl-text-bold\">Yes<\/span>\n            <i class=\"was-this-helpful__button-icon\">\n                <svg width=\"22\" height=\"22\" viewBox=\"0 0 22 22\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                    <g 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20.1213C10.4413 20.6839 11.2044 21 12 21L16 12V0.999995H4.72003C4.2377 0.994543 3.76965 1.16359 3.40212 1.47599C3.0346 1.78839 2.79235 2.22309 2.72003 2.7L1.34003 11.7C1.29652 11.9866 1.31586 12.2793 1.39669 12.5577C1.47753 12.8362 1.61793 13.0937 1.80817 13.3125C1.99842 13.5313 2.23395 13.7061 2.49846 13.8248C2.76297 13.9435 3.05012 14.0033 3.34003 14H9.00003Z\"\n                              stroke=\"#666666\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/>\n                    <\/g>\n                    <defs>\n                        <clipPath id=\"clip0_604_3423\">\n                            <rect width=\"22\" height=\"22\" fill=\"white\"\/>\n                        <\/clipPath>\n                    <\/defs>\n                <\/svg>\n            <\/i>\n        <\/button>\n    <\/div>\n    <span class=\"was-this-helpful__taken-action fl-text-sm-bold\"><\/span>\n    <div class=\"was-this-helpful__feedback-container\">\n        <div 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                 >Solved my problem<\/label>\n                    <\/div>\n                    <div class=\"fl-radio-button-field fl-flex was-this-helpful__feedback-form-title\">\n                        <input\n                                id=\"was-this-helpful__radio-button--other\"\n                                class=\"fl-radio-button-field-input\"\n                                type=\"radio\"\n                                name=\"positive-feedback\"\n                                value=\"Other\"\n                        >\n                        <label\n                                class=\"fl-radio-button-field-label fl-text-sm was-this-helpful__radio-label\"\n                                for=\"was-this-helpful__radio-button--other\"\n                        >Other<\/label>\n                    <\/div>\n                <\/fieldset>\n            <\/div>\n            <div class=\"was-this-helpful__feedback was-this-helpful__feedback--negative\">\n                <fieldset>\n                    <legend class=\"was-this-helpful__feedback-form-title\" tabindex=\"0\">Why was this not helpful?<\/legend>\n                    <div class=\"was-this-helpful__choose-option-message\" role=\"status\">\n                        <p class=\"was-this-helpful__choose-option-message-text\"><\/p>\n                    <\/div>\n                    <div class=\"fl-radio-button-field fl-flex was-this-helpful__feedback-form-title\">\n                        <input\n                                id=\"was-this-helpful__radio-button--missing-info\"\n                                class=\"fl-radio-button-field-input\"\n                                type=\"radio\"\n                                name=\"negative-feedback\"\n                                value=\"Missing Information\"\n                        >\n                        <label\n                                class=\"fl-radio-button-field-label fl-text-sm was-this-helpful__radio-label\"\n                                for=\"was-this-helpful__radio-button--missing-info\"\n                        >Missing the information I need<\/label>\n                    <\/div>\n                    <div class=\"fl-radio-button-field fl-flex was-this-helpful__feedback-form-title\">\n                        <input\n                                id=\"was-this-helpful__radio-button--complicated\"\n                                class=\"fl-radio-button-field-input\"\n                                type=\"radio\"\n                                name=\"negative-feedback\"\n                                value=\"Too complicated\"\n                        >\n                        <label\n                                class=\"fl-radio-button-field-label fl-text-sm was-this-helpful__radio-label\"\n                                for=\"was-this-helpful__radio-button--complicated\"\n                        >Too complicated \/ too many steps<\/label>\n                    <\/div>\n                    <div class=\"fl-radio-button-field fl-flex was-this-helpful__feedback-form-title\">\n                        <input\n                                id=\"was-this-helpful__radio-button--dated\"\n                                class=\"fl-radio-button-field-input\"\n                                type=\"radio\"\n                                name=\"negative-feedback\"\n                                value=\"Out of date\"\n                        >\n                        <label\n                                class=\"fl-radio-button-field-label fl-text-sm was-this-helpful__radio-label\"\n                                for=\"was-this-helpful__radio-button--dated\"\n                        >Out of date<\/label>\n                    <\/div>\n                    <div class=\"fl-radio-button-field fl-flex was-this-helpful__feedback-form-title\">\n                        <input\n                                id=\"was-this-helpful__radio-button--negative-other\"\n                                class=\"fl-radio-button-field-input\"\n                                type=\"radio\"\n                                name=\"negative-feedback\"\n                                value=\"Other\"\n                        >\n                        <label\n                                class=\"fl-radio-button-field-label fl-text-sm was-this-helpful__radio-label\"\n                                for=\"was-this-helpful__radio-button--negative-other\"\n                        >Other<\/label>\n                    <\/div>\n                <\/fieldset>\n            <\/div>\n            <div class=\"was-this-helpful__form-buttons-container\">\n                <button\n                    class=\"was-this-helpful__feedback-button was-this-helpful__feedback-button--positive at-feedback-submit fl-button secondary\"\n                    type=\"submit\"\n                >\n                    <span class=\"fl-button-content\">Submit<\/span>\n                    <i\n                        class=\"fa fa-angle-right medium\"\n                        aria-hidden=\"true\"\n                    ><\/i>\n                <\/button>\n                <button\n                    class=\"was-this-helpful__feedback-button was-this-helpful__feedback-button--cancel fl-button primary disabled\"\n                    type=\"reset\"\n                >\n                    <span class=\"fl-button-content\">Cancel<\/span>\n                    <i\n                        class=\"fa fa-times-circle medium\"\n                        aria-hidden=\"true\"\n                    ><\/i>\n                <\/button>\n            <\/div>\n        <\/form>\n    <\/div>\n    <div class=\"was-this-helpful__thank-you-message\" role=\"status\">\n        <i class=\"was-this-helpful__thank-you-message-icon fa fa-check\"><\/i>\n        <p class=\"was-this-helpful__thank-you-message-text\" aria-live=\"polite\"><\/p>\n    <\/div>\n<\/div>\n\n\n    <\/div>\n    \n    <div class=\"fl-section-sidebar\">\n        <div class=\"fl-editors-summary\" data-testid=\"fl-editors-summary\">\n    \n    <div class=\"fl-editors-summary-content\" data-testid=\"fl-editors-summary-content\">\n                    <h2>Can I Solve This on My Own or Do I Need an Attorney?<\/h2>\n                <div class=\"fl-editors-summary-content-main\" data-testid=\"fl-editors-summary-content-main\">\n            \n        <\/div>\n        <ul class=\"fl-list-style-none\">\n                            <li data-testid=\"fl-editors-summary-content-item\">\n                    <i class=\"fa fa-check medium fl-editors-summary-content-item-icon\" aria-hidden=\"true\"><\/i>\n                    Consumer legal issues typically need an attorney&#8217;s support\n\n                <\/li>\n                            <li data-testid=\"fl-editors-summary-content-item\">\n                    <i class=\"fa fa-check medium fl-editors-summary-content-item-icon\" aria-hidden=\"true\"><\/i>\n                    You can hire an attorney to enforce your rights for safe products, fair transactions, and legal credit, banking and related financial matters\n\n                <\/li>\n                    <\/ul>\n                    <div class=\"fl-editors-summary-content-description\" data-testid=\"fl-editors-summary-content-description\">\n                <p>Legal cases for identity theft, scams, or the Equal Credit Opportunity Act can be complicated and slow. 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<\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>Welcome to FindLaw&#8217;s section on insurance claims, with legal and practical information to help you understand the claims process, make the right choices, and protect your rights. Learn about bad faith insurance laws, adjusters, liability, and much more.<\/p>\n","protected":false},"author":41135,"featured_media":0,"parent":352567,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"app\/Http\/Controllers\/Templates\/ArticleWithBreadcrumbsController.php","meta":{"_acf_changed":false,"_stopmodifiedupdate":true,"_modified_date":"","_autodraft_ids":[],"_cloudinary_featured_overwrite":false,"_sb_is_suggestion_mode":false,"_sb_show_suggestion_boards":false,"_sb_show_comment_boards":false,"_sb_suggestion_history":"","_sb_update_block_changes":"","_is_real_time_mode":false,"_realtime_collaborators":"","footnotes":"","cf_checklist_status":[]},"categories":[2732],"tags":[],"state_laws_tags":[],"flmsa":[],"class_list":["post-352595","page","type-page","status-publish","hentry","category-consumer"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/pages\/352595","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/users\/41135"}],"replies":[{"embeddable":true,"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/comments?post=352595"}],"version-history":[{"count":0,"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/pages\/352595\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/pages\/352567"}],"wp:attachment":[{"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/media?parent=352595"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/categories?post=352595"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/tags?post=352595"},{"taxonomy":"state_laws_tags","embeddable":true,"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/state_laws_tags?post=352595"},{"taxonomy":"flmsa","embeddable":true,"href":"https:\/\/www.findlaw.com\/law-api\/wp-json\/wp\/v2\/flmsa?post=352595"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}