How to Fight a Denied Insurance Claim

Receiving an insurance claim denial is frustrating, but it's not the end of the road. Studies show that 50-70% of appealed claims are eventually paid, at least partially. This guide shows you how to fight back effectively and get the coverage you paid for.

Why Insurance Claims Get Denied

Understanding why your claim was denied is the first step to overturning it:

• Policy exclusions: Damage type isn't covered under your policy
• Lapsed coverage: Policy wasn't active when incident occurred
• Missed deadlines: Claim filed too late or documentation deadline missed
• Insufficient documentation: Not enough evidence to support the claim
• Pre-existing damage: Insurer claims damage existed before incident
• Maintenance issues: Damage attributed to lack of upkeep
• Disputed cause: Disagreement about what caused the damage
• Coverage limits exceeded: Claim exceeds policy maximums

Step 1: Get the Denial in Writing

Request a formal written denial letter that includes:

• Specific reason(s) for denial
• Policy language cited for the denial
• Claim number and date
• Contact information for appeals
• Deadline for filing an appeal

Step 2: Review Your Policy Carefully

Read your policy with fresh eyes, focusing on:

• The exact exclusion language they cited
• Definitions section - how key terms are defined
• Coverage sections that may apply
• Endorsements and riders that modify coverage
• Conditions and duties after a loss
• Appeal procedures and deadlines

Insurance policies use precise language. Sometimes denials rely on broad interpretations that don't match the actual policy text.

Step 3: Gather Additional Evidence

Build a stronger case with new documentation:

• Additional photos and videos of damage
• Expert opinions (contractors, engineers, specialists)
• Independent estimates for repairs
• Weather reports or news coverage of the incident
• Witness statements
• Maintenance records showing proper upkeep
• Proof of when damage occurred (before/after photos)

Step 4: Write Your Appeal Letter

A strong appeal letter should include:

• Clear statement: 'I am appealing the denial of claim #[number]'
• Summary of incident and claim
• Specific reasons you disagree with the denial
• Policy language that supports your position
• Reference to any new evidence enclosed
• Request for specific action (approval, re-review, etc.)
• Deadline for response (typically 30 days)

Be professional, factual, and persistent. Avoid emotional language. Stick to facts and policy language.

Step 5: Escalate Within the Company

If initial appeal is denied, escalate:

• Request supervisor review
• Contact the claims manager
• Write to the VP of Claims
• Ask for internal review by different adjuster
• Request to speak with the company's SIU (Special Investigations Unit) if fraud was alleged

Step 6: File Complaints with Regulators

State insurance commissioners regulate insurers and can help resolve disputes:

• File complaint with your State Department of Insurance
• Include all correspondence and documentation
• Explain why you believe denial is unjustified
• Regulators can investigate and pressure insurers
• Many disputes resolve after regulatory involvement

You can find your state insurance commissioner at the National Association of Insurance Commissioners (NAIC) website.

Step 7: Consider Professional Help

For significant claims, professional assistance may be worthwhile:

• Public Adjusters: Licensed professionals who negotiate claims on your behalf. Fee: 10-15% of settlement
• Insurance Attorneys: Handle bad faith cases and large disputes. Often work on contingency
• Appraisers: If you dispute the damage amount, many policies have appraisal clauses

Understanding Bad Faith Insurance Practices

Insurers must act in good faith. These practices may constitute bad faith:

• Unreasonable delays in processing claims
• Denying claims without proper investigation
• Misrepresenting policy language
• Failing to explain denial reasons
• Lowball offers without justification
• Refusing to pay undisputed portions of claims
• Intimidating or threatening policyholders

If you suspect bad faith, document everything and consult an insurance attorney. Bad faith claims can result in damages beyond your policy limits.

Appeal Strategies by Denial Reason

Tailored approaches for common denial reasons:

• Pre-existing damage: Provide dated photos, inspection reports, or neighbor statements proving condition before incident
• Maintenance/neglect: Show maintenance records, receipts, contractor statements about reasonable care
• Excluded peril: Challenge their characterization of the cause with expert opinions
• Late filing: Document extenuating circumstances (hospitalization, disaster-related delays)
• Coverage dispute: Get independent interpretation of policy language

Appeal Timeline

• Review denial letter: 1-3 days
• Gather additional evidence: 1-2 weeks
• Submit written appeal: Within 60 days of denial
• Insurer response: 30-45 days typically
• Escalation if needed: Ongoing
• Regulatory complaint: After internal appeals exhausted
• Legal action: Within statute of limitations (1-6 years depending on state)

Sample Appeal Letter Framework

Use this structure for your appeal:

• Opening: Claim number, date of denial, statement that you're appealing
• Summary: Brief description of incident and claim
• Disagreement: Specific reasons the denial is wrong
• Policy support: Quote relevant policy language
• Evidence: List new documentation being submitted
• Request: Clear statement of what you want (approval, re-review)
• Closing: Deadline for response, contact information

Key Takeaways

• Don't accept denials as final - most appeals have a chance of success
• Get the denial in writing with specific reasons
• Read your policy carefully - the answer may be in the language
• Gather strong supporting evidence
• Be professional, persistent, and documented
• Escalate through internal channels, then to regulators
• Know when to seek professional help
• Document potential bad faith behavior