If you file a personal injury lawsuit and make a claim with an insurance company, either your own or the other party’s claims adjuster may argue that the insurance policy covering your accident is invalid. The following factors could account for this type of response:
The policy has expired; the nature or location of the accident is not covered by the policy’s terms; the person who caused the accident is not covered by the policy, and you are not eligible to file a third-party claim under your state’s no-fault automobile insurance law.
Negotiations for personal injury compensation do not end when an insurance adjuster asserts that your accident is not covered. Rather than that, the coverage question becomes part of the negotiation process for the accident settlement. Jason Stone Injury Lawyers recommends you know the following about the process.
Responding to a Denial of Coverage
To begin, request a written explanation from the adjuster detailing the insurance company’s reasons for denying coverage, including any particular policy restrictions limiting coverage. This will disclose whether the adjuster is bluffing and will enable you to respond more clearly to the adjuster’s explanations.
If the adjuster refuses to provide you with a written explanation, write the adjuster a letter summarising your conversation, the coverage denial, and the adjuster’s reluctance to provide you with a written explanation. Because the claims supervisor of an insurance company will resent having such a letter on file, this letter may compel the adjuster to furnish you with the information. If you submit a claim with the insurance commission or a lawsuit, the presence of this type of letter in the claim file demonstrates the insurance company’s unwillingness to cooperate.
If the other party’s insurer refuses coverage, request a copy of the insured’s policy or, at a minimum, the parts on which the adjuster based his denial, so you can read it for yourself. If the adjuster declines, write him a note explaining why so that it becomes part of your claim file. If the adjuster refuses to negotiate a settlement with you, you will need to exert more pressure to kick-start the negotiations.
Frequently, an adjuster will assert that there is no coverage. The adjuster, on the other hand, will commence settlement negotiations immediately upon your declaration that you would not abandon your claim. If you are unable to achieve an agreement on the coverage problem, you will need to pursue alternate settlement bargaining strategies.
If the adjuster appears to be correct in saying that there is no coverage and is unwilling to discuss a settlement, you may be able to seek coverage from the third party who caused the accident. For instance, imagine you submit a slip and fall claim following a trip on a damaged sidewalk and the city asserts that you are not covered since sidewalk maintenance is the legal responsibility of each property owner. You could then file a claim with the insurance company of the property owner directly.
Coverage is determined by the policy’s provisions, and frequently, a policy can be read in numerous ways depending on the facts. If a dispute proceeds to court, the majority of policy ambiguities are resolved in favor of coverage. The bottom line is that the attorney’s perspective on the matter does not resolve it.