Insurance is meant to protect your finances when unexpected situations arise. Personal injury protection delivers a secondary benefit by assisting with medical coverage and income loss (along with many other benefits) if you’re injured in an accident.
Most PIP claims are approved quickly to ensure funds get dispersed. What happens if that approval doesn’t come through as expected?
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Can PIP Be Denied?
Insurance claims can be denied for several reasons. If the circumstances regarding your injury don’t meet the coverages outlined in the policy, this outcome may occur.
If you are injured and expect the PIP claim to be approved, you might feel confused, frustrated, or even helpless. Why are you even paying for this coverage if it doesn’t help when you need it the most?
When you understand why a personal injury protection claim can be denied, it’s easier to discover a solution that can reverse those circumstances.
What Can Cause an Insurance Claim to Be Denied?
PIP injury insurance claims aren’t denied often, but it is possible. Each situation is different, but these are the typical reasons why an insurer might decide against issuing a payout.
1. Lack of Evidence
When an injury claim is brought through PIP, there must be proof that the affected person sought treatment for a documented issue. Failing to report these circumstances within a specific time could be grounds for an adjuster to issue a denial.
Ask your doctor to provide the documentation to the insurance company directly. If that isn’t possible, request copies you can distribute yourself.
2. Treatment Delays
Most PIP claims get denied because the individual didn’t seek treatment within the specific time the policy requires. States typically want people to see a doctor within 30 days of a qualifying event.
Florida requires people to seek medical care within 14 days. Most other states require an examination between 14 to 30 days after the qualifying accident.
Washington, Maryland, and other states have a statute of limitations of three years to file a PIP claim if all the treatment paperwork and other documentation are available.
3. Location Restriction
Many PIP policies don’t provide coverage for accidents that occur outside of the United States. Some insurers might restrict claims to in-state incidents. If you find yourself in this situation and the accident isn’t your fault, the other driver’s liability insurance should cover your medical expenses.
4. Preexisting Injury
Another common reason for denying a PIP claim is that the individual already had a prior condition that physically affected them. If an adjuster believes the claim is attributable to an existing health issue, it will likely be denied.
Some claims are denied when applicants fail to disclose preexisting conditions.
5. Coverage Lapse
If you fail to pay your personal injury protection insurance premium, you won’t receive the benefits from the policy if something happens after it becomes inactive. Insurers send multiple notifications to ensure renewals occur, so try to stay current or sign up for autopay options when available.
6. Mitigation Failure
Some insurance adjusters might look at a case and believe the individual involved failed to take reasonable steps to prevent injuries or reduce recovery times. In that situation, they could deny a PIP claim.
Can an Insurance Company Deny a Claim Without an Adjuster?
Insurance companies can deny claims regularly. Adjusters work to review each incident to determine if there is an obligation to deliver a payout.
The rules surrounding this obligation change regularly, so it helps to know what to expect where you live.
This is important:
If an adjuster doesn’t look at your claim, there could be automated processes that prevent an expected payout from occurring. There might be missing information, incomplete paperwork, or photo requirements that haven’t been met.
In those circumstances, an insurance adjuster denies the claim if the system doesn’t do it automatically.
How Do You Fight an Insurance Claim Denial?
The first step is to contact the insurance company directly to dispute the denial. You’ll typically receive that information if you ask for ways to have the claim approved or improved. Follow whatever instructions are provided by the agent or adjuster.
Some claims are denied because the insurer thinks it is fraudulent activity. If you provide evidence of the issue, the claim is typically reversed.
If your insurer refuses to review the case and doesn’t offer a path to approval, you can request an independent inspection. Each community has public adjusters that can look at your evidence, but this service comes with an added cost. Many won’t ask for payment until a settlement or payout occurs.
You also have the option to file a complaint with your state’s insurance regulator and hire an insurance attorney.
Most PIP claims are approved. When a denial occurs, most of those issues are corrected by submitting the correct information. If an appeal isn’t available, knowing how to fight for what you’re owed can help reverse some decisions.
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