Legal Tips

Why Personal Injury Claims Get Rejected and How to Avoid It

When you suffer an injury due to someone else’s negligent or intentional actions, fairness — and the law — dictates that you deserve justice and financial compensation for your losses. For example, suppose someone runs a red light and hits your car. If you do not pursue a claim, the burden of your medical bills and lost wages falls on you.

Insurers do not pay injury compensation easily. You must provide evidence before an insurer accepts liability for your injuries. An insurer may also reject a claim strategically to frustrate you into withdrawing it or taking a low-value settlement.

Common Grounds for Rejection

Liability insurance policies obligate insurers to pay for losses incurred by third parties as a result of a policyholder’s negligence. 

An example can best illustrate this system: Doctors must buy medical malpractice liability insurance. When the doctor’s negligent actions injure a patient, the malpractice insurer must reimburse the patient for their losses. 

These losses might include reasonable and necessary medical costs, lost income, and out-of-pocket expenses. They can also include non-economic losses that take into account the patient’s reduced quality of life, such as pain, mental anguish, and disability.

Insurers assign insurance adjusters to investigate third-party claims. The adjuster reviews the claim and any supporting evidence. They may also talk to the policyholder to get their side of the story. To accept a claim, the adjuster must agree that the claim falls within the scope of the liability policy.

Claim adjusters can reject claims for many reasons, including the following:

Your Injury Did Not Occur in a Covered Event

Liability policies describe the scope of the coverage. Insurers can reject claims that fall outside of the scope of the policy. 

The policy will include a list of covered events. For example, auto liability insurance covers motor vehicle collisions. Thus, a slip and fall claim would get denied if you filed it with a property owner’s auto insurer.

A Covered Person Did Not Cause Your Injury

A policy will also name covered people. Thus, the malpractice policy for a medical office might list the doctors, nurses, and medical support staff who work for the practice. An insurance adjuster can deny your claim if you cannot prove who injured you or if the person who injured you was not on the policy.

However, this type of denial might open up another avenue to compensation. For example, suppose that you broke your arm when an EMT dropped you off of a gurney. If the hospital’s insurer rejects your claim, you might have a claim against the ambulance company instead.

The Policyholder Was Not Negligent

Liability policies typically only cover negligence. Thus, not all adverse outcomes will support an injury claim. Specifically, insurers will reject claims that did not result from negligence.

Suppose that you had an allergic reaction to a medication. However, no one, including you, knew of the allergy. A malpractice insurer might deny the claim since the prescribing physician could not have foreseen the reaction.

To prove negligence, you and your lawyer must have evidence that the other party failed in their duty of care. Generally, this standard is determined by how a reasonable person would act in the same situation. A doctor, for example, must provide reasonably competent, knowledgeable, and skilled care based on the patient’s circumstances.

If you fail to prove the other party’s negligence or if the circumstances show the other party fulfilled their duty of care, the insurer can reject the claim.

Your Losses Exceeded the Claim Limit

Liability policies have monetary caps. The insurer will pay claims up to, but not over, the claim limit. For example, New York requires all vehicle owners to buy at least $25,000 per victim in bodily injury liability insurance. If you incur $35,000 in losses, the insurer can pay up to $25,000 before rejecting the remaining $10,000.

Avoiding a Claim Rejection

When an insurer rejects a claim, you and your lawyer can respond with evidence or legal arguments. The claims adjuster might withdraw the rejection after seeing your response.

Preventing a rejection is often better than trying to overcome one. Some ways to avoid a claim rejection include the following:

Maintain records of what happened and what it cost you
Discuss all your symptoms with your doctor so they get recorded
Hire a knowledgeable lawyer who knows what you need for your claim

The third factor is critically important. During your initial consultation, a lawyer may review your documents and discuss how to obtain additional records to support your claim. For example, the lawyer may want to gather medical records, police reports, or witness statements.

Learn More From an Experienced New York Personal Injury Lawyer

Claim rejections can occur for many reasons, including insufficient evidence. The personal injury lawyers at Silberstein & Miklos will help you avoid or overcome rejections and fight for the injury compensation you deserve under New York law. 

Ask4Sam