Insurance

Filing a claim against another driver is called a “third-party insurance claim.” If the other driver is at fault, you can file a claim with the other driver’s insurance company for any accident-related property damage and medical expenses. If you filed a claim with your own insurance company and it’s providing coverage, your insurance company may bring a claim against the other driver or the other driver’s insurance.

Generally, you’ll file your third-party claim directly through the at-fault driver’s insurer. Your own insurance company may assist in guiding you through this process. When you’re ready to initiate your third-party claim, you will need to have the following information:

• The at-fault driver’s name and insurance policy number
• A copy of the official accident report. You can request this report from the responding police department
• The contact information for injured passengers or witnesses
• Photos of all the damages and the surrounding scene of the accident
• Your repair shop’s contact information
• Details of accident-related injuries – including dates of hospital stays

The most common forms of a claim denial in the context of an auto accident are:

• You file a claim with your insurance company and your company won’t pay what you believe the vehicle is worth
• You file a third-party claim with the at-fault driver’s insurance company and the company denies your claim

It is critical to understand the reason your claim was denied. If you know why the claim was denied, you can properly determine if you have reason to dispute the decision. Take careful steps to read the insurance company’s reason and review your policy.

If you elect to dispute the claim denial, the first step is to write a demand letter to your company, which we can help you do. In this letter, tell the company where it made the mistake, and provide documentation to support your position.

Your appeal likely hinges on proving that your treatment qualifies for coverage under your plan’s benefits and rules. In that case, you will want to zero in on the plan’s language and utilize the medical documentation to show why the procedure you are seeking fits into a category of care that the insurer has promised to pay for.

1. Figure out what led to the denial of coverage. When you call your health plan to get the information, take notes and get specific details.
2. Learn your insurance company’s appeal procedure for denied claims. You must adhere to this procedure, as it is likely outlined in your insurance contract, by which you are legally bound.
3. Gather the documents relating to the denial or rejection of your claim. This will include:
   1. The denial letter
   2. A copy of your plan’s full benefits language, sometimes called the “evidence of coverage”
   3. The detailed guidelines that explain what the insurance company considers medically necessary
   4. Any other medical records from your doctor, and any other doctor you’ve seen, relating to the denied medical treatment

After you have gathered these documents and learned the appeals procedure for your particular insurance company, utilize these documents in the implementation of that procedure.

Some claims are denied because it is unclear whether the treatment you seek is scientifically proven and medically necessary. If this is the case, in addition to the medical information listed above, ask your doctor to write a detailed letter on your behalf. This letter should include information and studies describing how the doctor knows the treatment has been medically proven and examples that demonstrate the treatment you want has worked in cases similar to yours. Additionally, the letter should include the doctor’s reasons why this particular treatment is medically necessary, as opposed to other alternative (and perhaps less expensive) treatments for the medical condition from which you suffer.