Basics of Insurance Claims in Car Accidents

Understanding the Basics of Insurance Claims

If you have been involved in a North Carolina car accident, knowing how to open, file and manage your insurance claim after an accident can help you avoid some major headaches associated with the claims process. A thorough and complete understanding of the accident claims process is essential to the success of your claim. More importantly, failing to appreciate the claims process and its unusual intricacies can be disastrous for your potential claim or case.

Two important entities govern the relationship between you and any insurance company: (1) the North Carolina Department of Insurance (NCDOI) and (2) an insurance policy, if applicable.

The NC Department of Insurance is the state regulatory agency that governs the insurance industry at large, presides over the licensing of insurance professionals and others, educates consumers about different types of insurance issues, handles consumer complaints related to insurance companies and manages several other insurance industry-related activities, such as insurance policy language and limitations.

An insurance policy is the document that governs the specifics of your relationship with a particular insurance company and details the terms and conditions of your relationship as an insured. The policy outlines the insurance company’s obligations to its clients (sometimes known as the “insured”) and the insured’s obligations to the company.

Filing an insurance claim is a voluntary process of seeking reimbursement for injuries or damages for an event that may be covered under the policy. The process begins when the insured opens a claim for reimbursement for injuries or damages with the insurance company. After the claim has been opened and the insured submits documentation or evidence that supports the alleged injuries or damages, the insurance company will evaluate the claims and decide whether to accept the claim or deny it. It is important to note that it is exceptionally rare for an insurance company to accept everything that the insured is claiming or has claimed as injuries or damages. The person assessing the claim may decide to accept only part of the claim and deny other parts.

When deciding whether or not to file a claim, you should read the language within your policy to figure out what types of coverage you have on your policy. Moreover, understanding the language and limitations within your policy will allow you to know exactly what the policy covers and what it does not.

If you are presenting a personal injury claim that includes medical expenses, you will need to submit a properly formatted and detailed doctor’s bill to the insurance company. A properly formatted medical bill will show any health insurance payments and co-payments made toward the bill and include procedure codes detailing what exactly you were treated for. If your claim includes property damage, such as damage to your vehicle, you will need to speak to the insurance company and likely create a separate claim for that injury.

IMPORTANT: Insurance companies bifurcate the claims process. Claims for compensation for injury to your person are known as bodily injury claims and are handled separately from property damage claims. A property damage claim is a claim for damage to your personal property, such as a vehicle, cell phone, mailbox, etc.

Once you have called and opened a claim with the insurance company, your claim will be assigned to a claims adjuster. It is paramount to remember that the adjuster works for the insurance company and not for you. While the adjuster is there to assist you, they do not represent you and are not acting to benefit anyone but their company’s interests.

The adjuster is assigned to your claim to assist the insurance company in evaluating your claim against that company, which often includes making in-person inspections of the accident scene and vehicle involved, gathering evidence, and reviewing medical bills and records. Furthermore, the adjuster is given the responsibility of determining whether the claim is covered under a policy and how much a particular claim may be worth, given the facts and circumstances.

Why are claims denied?

It is not uncommon for an adjuster to deny a claim if they feel that the evidence, documentation and facts support that decision. If the adjuster has denied your claim, it is important to discuss with them the rationale for the denial. You may want to take notes about what they have stated or even record the call, when appropriate. Understanding the adjuster’s reasoning can be helpful in requesting a reconsideration of the decision. It is unusual for an adjuster to change their mind, but it does happen from time to time, especially if you can support your rationale with evidence, facts and documentation.

Unfortunately, adjusters and insurance companies are notorious for denying cases and claims. If you plan on presenting your claim to the insurance company, you need to understand why claims are often denied:

  1. The relief sought is not covered under the insurance policy – lack of coverage.
  2. Misleading information or intentionally incorrect information was provided to the insurance company.
  3. There is no policy in effect.
  4. The relief sought is unreasonable or unsupported by the evidence showing the damages or injuries.
  5. The adjuster believes that you were contributorily negligent.

If and when an adjuster denies a claim or there is a dispute over the value of a claim, it may be helpful to request reconsideration of the denial or valuation. This reconsideration process is informal and rarely works. Should the adjuster be unwilling to accept the claim or increase their offer, you may wish to consider filing a lawsuit.

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