Why did my insurance company deny my claim?

When you put forward an insurance claim there are many reasons that the insurance company may deny your claim. We will outline the most common reasons for denial that we have experienced.

The Time Limit for Applying Has Expired.

In Ontario the time limit for making an insurance claim is two (2) years from the date of the incident giving rise to the application. If this date is missed, the claim will be rejected, regardless of merit. Not being aware of the limitation is not an acceptable reason for missing the time limit.

The Application is Incomplete or Contains Errors.

This one is straightforward and can be solved by the applicant resolving applications shortfalls and resubmitting the application provided you are not facing a limitation problem.

Pre-approval for Expenses Was Not Obtained.

Many policies have a stipulation that they will only pay for certain items if you have obtained a quote and the cost has been established in advance. An example for illustration purposes; a roof damaged by a tornado. Before your insurance company pays for a new roof, they will want to see multiple quotes. If you do not provide these, no payments will be made, and the claim will eventually be denied.

Another example is hotel expenses following a fire. Yes, the insurer will cover those costs, but they will need to be pre-approved so you are not left with a large out of pocket expense when it comes time to pay the bill.

Claim Exceeds Policy Limits.

An insurance policy has limits on how much compensation is payable. If your application claims amounts exceeding the limits, the claim will be denied for any portion over the policy maximum.

Categories of coverage cannot be combined. You may have property insurance to cover a basement flood due to a water back up that indicates you have coverage for temporary living accommodations as well as a daily allowance maximum for restaurant meals. Not using one does not increase the availability of the other.

Not Disclosed Pre-existing Conditions or Otherwise Materially Changing the Level of Risk Being Assumed by the Insurer.

Insurance premiums are set by the insurance company by balancing risk vs possibility of loss. If your situation changes and you did not advise your insurance company, the likelihood of your claim being denied is high.

Examples for illustration purposes; travel insurance and a recent diagnosis of high blood pressure or property insurance where part of your home is inhabited by tenants.

You Underinsured Yourself, Either Knowingly to Save Money or Unwittingly by Not Understanding the Value of the Item Being Insured.

When purchasing insurance for your house and property it may be necessary to have appraisals done for jewelry, antiques, or art so they can be insured for full replacement value. This will increase the cost of your premiums but will confirm your ownership and streamline reimbursement for loss, damage, or theft.

Your policy needs to be reviewed before your next renewal date to confirm the amount specified for your possessions is adequate.

The Insurance Adjuster Relies on a Hired Expert to Deny the Claim.

All insurance companies have experts who will opine on a multitude of issues. Engineers to address structural and mechanical matters; medical specialists to determine the gravity of a personal injury or disability; accountants to trace financial transactions and losses. With a denial based on an insurance expert you will need to counter with one of your own. This is when having an experienced lawyer to consult is recommended.

The Company Has Reason to Believe the Claim is Fraudulent.

Insurance fraud has risen to significant levels and therefore most claims are being questioned. Don’t panic. If there is no deceit involved the situation can be addressed by retaining an experienced Insurance lawyer.

When you are looking for a lawyer following the denial of your claim, remember that lawyers do not fall into the category of one size fits all. Like medical specialists, you don’t go to a gynecologist to get a knee replacement or an ENT for a gastrointestinal issue. Lawyers also specialize and limit their practice to what they are good at.

When we talk about insurance claims, they come in so many shapes and sizes and the insurance disputes we handle include;

• Property damage, flood;
• Property damage, fire;
• Off road vehicle, liability;
• Property damage, sewer/water back up;
• Travel insurance, trip cancellation and/or out of country treatment;
• Home equipment breakdown;
• Tenant vandalism;
• Special coverage jewelry/art;
• Motor vehicle injury claims, Plaintiff & Defendant;
• Statutory Accident Benefits.

Michelle Brown limits her practice to personal injury, (including asbestos) insurance claims (partial list above), Will preparation and estate administration. No family law, no real estate transactions, no business contracts, no workplace compensation claims. We can refer to other lawyers as Michelle has deep ties to the Durham Region Law Association after many years of serving on the board and meeting most of the local legal community.

If after reviewing this information and our website you have questions about matters Michelle Brown is able to help you resolve, please contact us to arrange for an initial consultation.