What If the Claims Adjuster Denies Coverage For My Injury?

If you have a personal injury case and you end up filing a claim with an insurance company—your own or the other party's—a claims adjuster might argue that the insurance policy involved doesn't cover your accident. The reasons given for this kind of response might be:

• the policy lapsed
• the nature or location of the accident wasn't covered under the terms of the policy (particularly if it's a homeowner's policy)
• the person who caused the accident isn't covered under the policy, and
• you don't qualify to make a third-party claim under your state's no-fault car insurance law.

What Does a Coverage Denial Mean?

When an insurance adjuster contends that there is no coverage for your accident, that doesn't necessarily end personal injury settlement talks. In a certain light, the coverage question could simply become one more element in the injury settlement negotiation process.

In some cases, an adjuster will initially contend that there's no coverage. But as soon as you indicate that you won't abandon your claim, the adjuster might begin to negotiate a settlement anyway.

But in general, what are your options at this point?

Ask the Adjuster to Put It In Writing

First, ask the adjuster to give you a written explanation of the insurance company's reasons for claiming there's no coverage, including references to the specific policy provisions that limit coverage. This will do at least two things:

• reveal whether the adjuster is just bluffing, and
• give you a chance to respond more specifically to the reasons behind the coverage denial.

Get more tips on first discussions with an insurance adjuster after an accident.

Write Your Own Letter Documenting the Coverage Denial

If the adjuster doesn't agree to give you a written explanation, write a letter to the adjuster confirming:

• your conversation
• the denial of coverage, and
• the adjuster's refusal to explain, in writing, their basis for their decision.

This letter may pressure the adjuster to come to the table with more details, because a claims supervisor won't like having this kind of letter in the insurance company's file. If you eventually go to the insurance commission or file a lawsuit to pursue your claim, the presence of this kind of letter in the claim file could show the insurance company's lack of cooperation (and could suggest improper negotiation tactics or even "bad faith").

Get a Copy of the Relevant Insurance Policy

If the other side's insurer is denying coverage, ask the claims adjuster to provide you with a copy of the insured's policy—or at least the portions on which the adjuster relies in denying coverage—so that you can read it for yourself.

If the adjuster refuses, write a letter to the adjuster confirming the refusal so that it becomes a part of your claim file.

Then, if the adjuster still refuses to negotiate with you about settlement, you'll have to use other pressures to get negotiations moving.

Look for Other Insurance Coverage Options

If you've done your homework and the adjuster indeed seems correct that there's no coverage under the company's policy, you may be able to turn to other sources of insurance coverage.

For example, suppose you file a slip and fall against the company that maintains the apartment building where you live, because a broken stairway hand rail caused you to fall. The insurance adjuster seems to be correct in arguing that the accident happened outside the "common areas" that the company has contractual responsibility for. In this situation, you might see if the property owner's liability insurance policy might cover your accident.

Don't Be Swayed by a "Lawyer's Letter"

In claiming that there's no insurance coverage for your accident, an adjuster may tell you that "the lawyers" have said there's no coverage. The adjuster may even send you a copy of a letter from a company lawyer echoing that "fact".

Don't be intimidated. A company lawyer's opinion that there may not be coverage for your accident is no more binding than anyone else's opinion. Whether or not there's coverage depends on the terms of the policy, and a policy can often be read in several different ways, depending on the facts. If the matter goes to court, ambiguities in a policy are often resolved in favor of finding coverage. Bottom line: The lawyer's opinion doesn't resolve the matter.

More Information and Help

If you've suffered any kind of injury, and you're having trouble getting the at-fault party's insurance company to take your claim seriously, it might make sense to discuss your situation—and your options—with an experienced legal professional. Learn more about when you might need a lawyer's help and get tips on finding the right injury lawyer for you and your claim.

You'll find a lot more details on negotiating an injury claim—plus strategies for dealing with an insurance company that's refusing your claim—in How to Win Your Personal Injury Claim, by Joseph L. Matthews (Nolo).