At the time of the denial, it is customary for claim representatives to tell insureds that they will have an opportunity to appeal the denial and that the appeal will be a “fresh look” at the evidence in the file. Recently, we here at Kantor & Kantor have seen a new trend with some insurance carriers when there has been an initial denial of benefits. Some carriers are now providing insureds with a one or two page “appeal form” to be completed by the insured for the appeal. This is misleading and may actually prejudice the insured when completing the appeal.
As discussed in other posts on this website, the appeal to the insurance company is perhaps the most important part of a claim prior filing a lawsuit. It is the only opportunity for an insured to ensure that all of the evidence supporting his or her claim is in the insurer’s claim file. As such, an insured needs to include all medical records and testing documenting his or her impairments. If it is not included within the insurer’s claim file at the time of the final denial of the claim, it is very difficult, if not impossible to persuade a trial judge to consider the evidence. Thus, the mere completion of an appeal form, without the additional documentation, may cause an insured to believe that a few sentences, “explaining” the disability, may cause an insurance company to overturn its decision. In truth, it will not. The insurance company will deny the claim on appeal and its claim file will be incomplete, without the evidence that should be included to prove disability.
The insured should not be misled into believing that completion of a simple form will be sufficient to overturn the decision on appeal. The insurer’s claim file should be obtained to review the evidence in support of the denial and the denial letter should be carefully scrutinized. Once this is done, an appeal should be thoroughly prepared to rebut the insurer’s evidence.
California Insurance Lawyer Blog
