Handling Insurance Claims on Your Own

HANDLING SMALL INSURANCE CLAIMS ON YOUR OWN

Filing a claim with an insurance company can be frustrating. Complex claims involving large amounts of money or third-party liability for damages like pain and suffering should almost always be handled by attorneys, not laypersons. Some small claims, however, for medical services, disability benefits, durable medical equipment and the like can be more routine. This article offers some practical suggestions for presenting such small claims on your own.

Review your policy. Insurance policies are perhaps the most purchased but least read writings in existence. It is important to read your policy thoroughly so you understand your rights. You should specifically check what is covered and what is not covered and any reporting requirements and deadlines for presenting a claim. Make sure that your version of the policy is complete. Does it contain all applicable endorsements and exclusions? If you have any questions about the policy, ask your agent, broker or claims administrator. The time to ask is before you make a claim.

Evaluate the relevant terms. Many laws require that insurance policies use "easy-to-read" language. You should not have to hire a lawyer just to interpret your policy, at least initially. Here are some simple rules of thumb. Generally, words are construed according to their usual, plain meaning -- unless a specific definition is separately set forth in the policy. Ambiguous or unclear language is typically interpreted in favor of the individual-claimant and against the insurance company. Provisions are also construed according to the reasonable expectations of laypersons. Be sure to review any brochures, pamphlets or ads used to promote the policy as well. Such representations may help prove the insurer's promise to cover your claim.

Act promptly. Once you decide to make a claim, contact your agent or the insurer's representative as soon as possible. Many policies have filing deadlines that require notification within a certain time frame. Getting your agent involved at the start may help expedite the claim and get you some personal attention as well.

Support your claim. Have ready all documents that prove the points you need to make. File copies with your claim. Save the receipts for any items for which you claim reimbursement. Obtain copies of all medical records and reports which may be relevant. Sign authorization forms and/or waivers, if necessary, in order to obtain such records. Keep an inventory of all paperwork and a duplicate set of all records and receipts in case the originals are misplaced by the insurer or an agent.

Maintain a log of any contact. Write down the date, time and facts concerning every verbal, electronic or written communication that you have with the insurance company, claims adjusters or investigators in case there is a dispute in the future. Keep notes of the name, title and telephone number of each person with whom you have had contact. Keep a record of all statements and representations these individuals may make about your claim.

State your claim clearly. Be precise in any correspondence that you send the insurance company. Never exaggerate any details. Any misstatements that you make could be used to discredit you later. Avoid harsh, threatening or angry language which could alienate the reader. Try to resolve any disputes informally. Do not threaten to involve a lawyer or falsely imply that you have consulted with one. If insurers believe that attorneys may be involved, they may hesitate to communicate with you directly. Do not sign a release, unless your claim has been completely paid or you are completely satisfied with the outcome. If you are not satisfied and need additional help, consider contacting your state's insurance department.

Seek help from your state insurance department. Each state has its own claims handling laws and a department that regulates insurance companies within its jurisdiction. If you feel that an insurer is not acting reasonably, contact your state's insurance department. Insurance departments have the power to impose a variety of penalties if an insurance company has mishandled your claim or acted in bad faith. You can reach the department by telephone, mail or on-line. Include your policy or claim number on any correspondence and enclose any supporting documentation.

Consider retaining an attorney. If the insurance department has not been helpful, consider hiring an attorney who specializes in insurance and/or consumer protection law. Clarify how the attorney will be paid (e.g., hourly rate, contingent fee, etc.) from the start. If the insurance involved represents an employer-sponsored benefit, a special Federal statute (the Employee Retirement Income Security Act or ERISA) will apply and preempt other remedies available under state law. This statute, however, awards attorney's fees to prevailing parties.