Facing the news that your disability insurance claim has been denied in the wake of a major personal injury, a psychological breakdown from a condition such as severe depression, or even a serious medical condition not related to an acute accident, can be gut-wrenching. You or a loved one could still be in hospital, struggling to recover or beginning rehabilitation, only to be told by your insurer that, for any number of reasons, your claim has been rejected.

It’s important to note that you’re not alone. It’s common for insurance companies to deny claims because doing so benefits their bottom line. As noted in a previous blog, insurers earn money from collecting premiums, not for paying for their clients’ recovery. As such, insurance companies benefit from making the claims process slow, complex and uncertain. They know that claims must be filed accurately, within strict timeframes and in accordance with often complex fine-print provisions. They also know that many claimants won’t understand those requirements or their rights and won’t enlist the expertise of a qualified personal injury law firm to ensure their file is properly managed.

These and other factors can make it easier to deny your claim. The solution is to understand this process before it begins and to prepare yourself with the correct information. Seeking the right legal advice is the key to ensuring you obtain the coverage to which you’re entitled en route to making a full recovery from your personal injury.

Why insurance claim denials happen

It isn’t always the nature of the personal injury that results in a claim denial. Often, it’s a procedural or administrative error that makes it easy for an insurance company to reject your rightful claim. One of the most common is missing claim deadlines (which vary by policy) or providing insufficient medical documentation with objective evidence including diagnostic testing, imaging and expert testimony. In many cases, a third-party health care provider’s accurate diagnosis will be disputed or rejected by the insurer’s medical team. Again, it is in the insurer’s interest to claim that you’re able to work or haven’t had your lifestyle significantly impacted by your injury. Only your medical team can objectively determine when you’re well enough to return to pre-injury levels of work or other activities.

Another reason for a rejection is the determination that a pre-existing condition or disability (potentially unreported) either caused or exacerbated your injury and justifies a claim exclusion. Lastly, insurers will even resort to behind-the-scenes research or surveillance to determine the veracity of your claim. This could mean investigating your daily activities to determine whether they align with the injuries and degree of disability being claimed. That can even include reviewing social media accounts for evidence. If you’re posting about your recent 10 km run and the fun you had playing flag football, but claim you’re too injured to work, insurers will leverage evidence such as this to support their denials.

Steps to take if your insurance claim is denied

If you’ve already engaged a personal injury law firm, discuss the claim denial and allow them to manage the appeal process with your insurer (more on that in a moment). If not, focus on the facts. Read the denial carefully and understand the exact reason(s) why the insurance company has denied your claim. A careful parsing of the facts will help you determine a strategy to ensure your claim is eventually paid. This process should happen immediately to allow time for appeal—again, many policies include tight timelines for claims and appeals—to consult with your health care team to gather necessary medical documentation, or to address claim errors.

At this point, you may need to request a more detailed medical report from your doctor/healthcare providers. These are busy professionals who can sometimes fall short in providing adequate prognosis or treatment history details, along with an outline of your current and future level of disability, pain or suffering. Providing additional lab or imaging results can also be beneficial, along with records of medical examinations, treatments and communication with your insurer. Being organized and detailed will only increase your odds of a successful appeal of a claim denial.

Engaging a personal injury law firm

A best practice at the appeal stage is to work with your personal injury lawyer and allow them to manage the process. A qualified lawyer will understand that most policies allow for an appeal, to submit new medical evidence and clarifications and the format most likely to ensure success. There’s another benefit.

Experienced personal injury law firms such as Leone Murray LLP have a reputation for effective litigation. Insurers understand that firms such as ours have the expertise and will take the time to pursue a denied claim until we achieve an outcome that’s in our client’s best interests. By managing all communications on your behalf, explaining the complex clauses of your insurance policy and escalating the matter—by taking your case to court, if necessary—we can deliver the results you both need and expect.

Remember that an insurance claim denial is the beginning—not the end—of a legal process that can be won with an effective strategy. Many policyholders who assume their claims are definitively rejected have been pleased to see them upheld on appeal. It’s all possible with the right evidence and legal guidance.

The Leone Murray LLP Team

If you’ve sustained a significant personal injury, know that the Leone Murray LLP team is here to provide expert legal guidance and support. Our compassionate team is dedicated to helping you manage the legal process and obtain the compensation you deserve. Contact us today for a free case assessment.

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Why choose Leone Murray LLP

Expertise: Our law firm specializes in personal injury law, which means we know the ins and outs of insurance, what you’re entitled to, and the next steps if you or your loved one is involved in a motor vehicle accident in Ontario.

Compassionate Care: We take a client-first approach, ensuring you receive both the legal expertise and emotional support you need during this difficult time.

No Upfront Fees: Some insurance providers may require you to take on additional costs related to medical assessments or specialist treatments. We pay these upfront fees on your behalf while fighting for your rights, saving that added stress so you can focus on your complete recovery.