An Overview Of Claim Denials And How To Fight Them In Court

An Overview Of Claim Denials And How To Fight Them In Court

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For almost any accident or disability claim, relief often hinges on the claim’s approval. It should come as no surprise that insurance companies are, to a large degree, in the business of denying claims when legally defensible. Otherwise, their next natural motive is usually to press their policyholder’s victims into a drastically reduced settlement.

It’s exactly the last thing one needs after experiencing a traumatic, life- and career-limiting injury, whether because of someone else’s negligence or at the workplace. That’s the situation a Scott County 911 dispatcher faced after an unusually disturbing call left her deeply traumatized and unable to work.

By pressing back on the initial claim denial, she achieved relief not only for herself – she made it easier for others facing similar situations to obtain the compensation they’re entitled to.

Types of Claim Denials

Insurance companies and compensation commissioners can be incredibly creative in the arguments they put forward when attempting to deny claims. As a result, there are far more types of claim denials than there are types of claims – meaning your legal representation must be even more clever and diligent in pressing back.

Generally, any claim placed before a court or administrative agency can be denied, and for almost any number of reasons. Even the most valid claims can be denied if one signs a liability waiver or fails to pursue the matter further, unsure or unaware of how valid their claim really is. The following are some of the most common types of claims denials frequently encountered by those seeking relief for their injuries.

Workers’ Compensation

The case cited at the beginning is an example of a workers’ compensation claim. In the state of Iowa, a workers’ compensation claim hinges on proving a workplace injury was unexpected or unusual in some way.

Reasons for Workers’ Comp Claims Denial

Denial of workers’ comp claims can occur for a variety of reasons. Workers’ comp claims are often more complex than non-workplace injuries, because it involves contractual obligations with an employer that can easily alter the threshold for what the courts will view as “unusual” to the scope of employment.

Other reasons include:

  • An injury occurred due to non-work-related activity
  • Allegations of some kind of wrongdoing
  • Employment status at the time of claim
  • Missed deadlines on the workers’ comp application or reporting of the injury

Note that there are legally defensible reasons for delays in filing a workers’ comp claim, and being fired in retribution for filing a claim is illegal.

Disability Claims

Disability claims are granted or denied according to a broad category of legally defined “substantial gainful activities” (or SGAs). An SGA is any significant physical and/or mental activity that can be done for pay or profit. There’s also a profitability threshold for SGAs, which is $1310 per month in the state of Iowa.

Reasons for Disability Claims Denial

Supplemental Security Income (SSI) or Social Security Disability (SSD) claims can be denied on the basis that a disability doesn’t meet the legal definition of an SGA. They can also occur due to application errors or omissions.

Because disability claims are pursued through what are essentially federal agencies, claim denials usually result in an appeal process, rather than litigation – although a court order is a possible remedy.

Vehicle Accidents

Depending on the nature of a vehicle accident, a claim may be very easy to obtain or quite difficult. Claims for accidents involving pedestrians or cyclists, especially with the right of way, are hard or impossible to deny (given competent legal counsel). Accidents between drivers often lead to a veritable evidence battle to determine fault. .

Reasons for Vehicle Accidents Claims Denial

Because Iowa is an “at-fault” state, car insurance claims usually require more thorough proof of negligence, and the stakes are higher to prove (and thus deny) liability in vehicle accident claims. 

If a commercial driver is involved, the matter becomes even more legally complex. In any case, vehicle insurance adjusters have been known to:

  • Blame the injuries on preexisting conditions
  • Disprove fault
  • Use out of court statements against the claimant

The waters become murkier when insurance companies twist voluntary statements in an attempt to obtain legally admissible evidence suggesting that the wronged party actually admitted liability for the accident. It’s important to direct all communications about active claims through legal counsel.

Personal Injury

Besides vehicle accidents, which are a form of personal injury, the term personal injury encompasses a broad category (e.g., slip and falls, dog bites, defective products, wrongful death, etc.). Almost any proven injury, property damage, or lasting psychological distress directly caused by another’s negligence can result in a personal injury claim.

Reasons for Personal Injury Claims Denial

Of course, personal injury claims can be denied on the same basis that they’re made – whether negligence exists or not. The defense in a personal injury claim only has to disprove any of:

  1. The existence of a legal duty
  2. Breach of that legal duty
  3. That breach of a legal duty directly caused the injury

Medical Malpractice

Medical malpractice claims are more vigorously denied, in part because of heated disagreement over the liability borne by major medical institutions. A medical malpractice claim is often more difficult to pursue, but the compensation potential is very high.

Reasons for Medical Malpractice Claims Denial

Sometimes, medical malpractice claims for the misconduct of trusted medical professionals are denied on the basis that the injuries were more directly caused by a defective product. Again, the actual liability of medical product makers becomes hotly contested. In either case, the opposing counsel will likely assert and attempt to prove the medical professional or product manufacturer followed proper protocols and met professional standards.

A medical malpractice claim is more likely than the others mentioned to become litigious – but as we’ll explain, the vast majority of claims result in settlements, not trial.

How to Fight a Claim Denial in Court

Claim Denial Law

First, it’s important to understand that most claims result in settlements. However, the chances of obtaining full compensation for an injury are much higher when a claim is as robust as possible. Claims groomed for success from the very beginning are more likely to achieve either (1) an adequate settlement or (2) a timely and sizable court verdict.

Advantageous negotiations are only possible when the claim is properly filed, and when it’s backed by solid, court-admissible evidence. For instance, pressing back on a medical malpractice claim denial is more likely to require expert witnesses than other types of cases. Higher profile cases can similarly test the ability of attorneys to call the other side’s bluff.

As any claim denial issue moves closer to trial, the opposing side becomes much more likely to at least tacitly admit liability and offer a reasonable settlement. It’s essential that your legal counsel has equally extensive experience with settlement negotiations and court representation.

Navigating the Claims Process for Maximum Success

To ensure the fullest possible recovery – both physically and financially – an experienced personal injury and disability lawyer won’t be deterred by attempts at denying a claim. In fact, they’ll expect it and be prepared to use it to their client’s advantage.

Fortunately, fees for personal injury claims are normally paid on a “contingency” basis, where attorney costs are taken from a successful settlement or court order. Personal injury attorneys also usually provide free consultations to learn about your case and provide an estimate of what it’s worth and what’s required to strengthen and pursue it.

If you’d like to book a consultation with a highly experienced Iowa law firm with a long track record of success, call us at 515-444-4000 or reach out to the experienced attorneys at Mueller, Schmidt, Mulholland & Cooling (MSM&C).