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Why are Insurance Claims Generally Denied?


After a car accident, you will likely open a claim with the at-fault driver’s insurance company. You may be counting on the recovery proceeds to pay for your medical bills and other costs. However, unfortunately every case is different, and your claim may be denied by the insurance company for a variety of reasons. Understanding why claims can be denied may help you to frame your claim in a manner that could lower your chances of a denial. Provided below are some common reasons that personal injury claims are denied.

Contributory Negligence

Contributory negligence is by far the leading cause for denial of a personal injury claim. North Carolina is one of only four states that still upholds the legal theory of contributory negligence. Under this rule, whenever a person is found to share any responsibility for his or her damages, they are barred from recovering compensation for those damages. This means that even if you are found to be only 1 percent at fault, you cannot collect damages from the other party, despite the other party being 99 percent at fault. Therefore, if you are found to be even the slightest bit at fault, your claim will likely be denied. For further information on contributory negligence, please see the following link.

Contributory negligence comes with harsh consequences. Being aware of these consequences can help prevent you from making certain mistakes that will almost always lead to a contributory negligence defense by a claims adjuster. For instance, making statements at the scene of the accident such as “I’m sorry” or giving a recorded statement to the insurance company with a poor explanation of fault may cause your claim to be denied.

Waiting too Long After the Accident to Seek Medical Treatment

Generally speaking, people do not enjoy going to the doctor or emergency room. However, if you are injured in an accident, avoiding medical treatment can be detrimental to you and your claim. In order to prove that your injuries are a direct result of the accident, it is imperative that you seek treatment right away or soon thereafter. Delays in treatment may provide the at-fault driver’s insurance company the opportunity to make the argument that your injuries did not occur as a result of the accident. The longer you wait to seek treatment, the stronger the case the insurance adjuster will have in denying your claim.

Seeking treatment immediately after your accident and having your injuries diagnosed early on provides you with a much stronger basis in causation for your personal injury claim. Furthermore, avoiding medical treatment may cause the insurance adjuster to believe that you are “faking” or exaggerating your injuries in order to receive a recovery. While you may, in fact, be injured, an insurance adjuster is in the business of protecting their company’s interests; therefore, adjusters are likely to use anything they can to support a denial.

Furthermore, certain portions of your claim may be denied when treatment lapses for a period of time. For instance, if go to physical therapy for two consecutive weeks following your accident, stop going for a month, and then decide to start back again, a claims adjuster will likely only reimburse you for the first two weeks. Insurance companies do not like to pay for treatment that is deemed “unnecessary.” Therefore, it is important for you to follow through completely with your medical treatment plan as ordered by a medical professional.

Pre-existing Condition

If you have an injury that occurred before the accident, known as a pre-existing condition, a claims adjuster may deny or severely limit your claim for reimbursement for care pertaining to that injury. Claims adjusters will use the argument that your pre-existing condition is the cause for your pain and injury, and not the accident.

You are, however, entitled to damages for physical or mental conditions that were exacerbated by the accident. Claims adjusters love to deny claims based on the existence of pre-existing injuries. With this being said, you should be aware and cautious when claiming compensation for injuries that may have already existed before the accident. For more on how pre-existing conditions may affect your claim, read our article on Pre-existing Conditions. (link)

Your Medical Records do not Support any Injury

In order to prove that the other driver is liable, you must be able to establish all four elements of negligence: 1) duty 2) breach of that Duty 3) causation, and 4) damages. Medical records help indicate that you actually suffered an injury, making you entitled to damages. Without medical records, your personal injury claim will likely be denied since you are not able to prove damages.

For a general overview on negligence, please visit the following link.

Expired or Lapsed Policies

In North Carolina, all drivers are required to carry some form of car insurance. Unfortunately, not all people drive with insurance. This situation often occurs when a driver did have insurance, but it expired due to a failure to pay the premiums. More than likely, you will not find out that the at-fault driver’s policy was expired until after you file your claim with the driver’s insurance company. If the insurance has expired, the insurance company will not be liable and will deny your claim.

Misleading or Incorrect Information

Insurance companies are very good at investigating and seeking out truthful information. Therefore, if at any time an insurance company believes or finds that untruthful or exaggerated information has been provided, they will likely deny your claim. It is very important that you do not intentionally submit false or misleading information when opening a personal injury claim, as doing so can not only result in a denial of your claim, but may also amount to fraud, which is a felony in North Carolina.

Whenever your claim is denied, do not immediately give up. The fact that a claim is denied does not mean that you have no other recourse of action. When your claim is denied, always ask the claims adjuster for information as to why the denial occurred and request that the adjuster reconsider the claim. If the claims adjuster is unwilling to reconsider, you may wish to explore filing a lawsuit or contacting an experienced personal injury lawyer in your jurisdiction.

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