What Happens if Your Insurance Claim is Denied

Car accident claims in Florida are handled slightly differently from car accident claims in most states. Florida is a no-fault insurance state for automobile insurance. That means that each driver must purchase Personal Injury Protection (PIP) insurance coverage to protect themselves if they are involved in a car crash.

PIP insurance pays benefits to the insured, regardless of who caused the accident. Instead of filing a claim with the insurance company of the driver who caused your car accident, you file your claim with your PIP insurance carrier. You can only file a claim against the driver who caused the car accident if you sustained a “serious injury” as defined by Florida’s insurance laws.

There are advantages to having no-fault insurance. Claims are paid much quicker because you do not need to prove who caused the car crash. Therefore, you can get the money you need to pay medical bills and replace lost income.

However, PIP coverage only pays for 80 percent of your medical bills. It also pays just 60 percent of your loss of income. PIP insurance does not compensate you at all for your injuries, pain, suffering, or other damages.

Since you do not need to prove fault for a car accident claim, the PIP process should be easy. That is not always the case. Car accident claims are denied for many reasons. 

Why Was My PIP Insurance Claim Denied?

The fact that Florida has a no-fault insurance system for car wrecks does not mean that insurance companies do not deny claims. Insurance companies always look for ways to deny or lower the value of accident claims. The fact that you are dealing with your insurance company for a PIP claim does not mean that you will be treated fairly.

Some reasons that your PIP insurance claim could be denied include:

  • You failed to seek medical treatment without 14 days from the date of the accident as required by your PIP coverage
  • The medical treatment received was not provided by a licensed physician or facility
  • The medical treatment was not necessary or reasonable
  • The injuries you sustained were not an emergency medical condition that qualifies for compensation up to your policy limits
  • The car accident did not cause your injuries, or your injuries were from a pre-existing condition 
  • You were driving under the influence, or you intentionally caused the accident
  • You were driving a stolen vehicle or committing a felony at the time of the accident
  • The accident or injuries are excluded from coverage under your policy

If you receive a denial of your PIP claim, immediately request an internal review of the claim. The denial letter should contain instructions for filing an appeal. It is crucial that you follow the instructions and file the appeal correctly before the deadline stated in the denial letter.

What Happens Next?

When you request an internal review, your claim is reviewed by another person with the insurance company. 

You can help your appeal by reviewing the denial letter carefully. Note why the insurance company denied the claim and work to fix the problem. You might need to provide additional information or documentation.

If the claim’s internal review is denied, you can speak with a car accident lawyer about filing a PIP lawsuit. If the insurance company wrongfully denied your PIP claim, you could recover the compensation you should have received from your PIP claim. You may also recover additional compensation for losses caused by the wrongful denial of a claim.

Can I Sue the Other Driver Who Caused the Car Accident?

If your injuries meet the serious injury threshold, you could also file a claim against the other driver’s liability insurance policy. Florida does not require drivers to purchase liability insurance for car accidents. However, many drivers carry liability insurance to protect them if they are sued for a car accident claim.

Liability car insurance compensates victims when a driver causes an accident. A settlement of a liability insurance claim can include compensation for all medical expenses and all loss of income. 

Unlike PIP insurance, you may also recover compensation for other damages such as:

  • Physical pain and suffering
  • Disfigurement and scarring
  • Disabilities and permanent impairments
  • Mental anguish and trauma
  • Loss of quality of life
  • Other out-of-pocket expenses 

If the liability insurance company denies your claim or the at-fault driver does not have liability insurance, you might want to seek advice from a car accident attorney. You could file a lawsuit against the driver seeking compensation for damages. A lawyer can advise you of all your options and help you choose the option that gives you the best chance to recover maximum compensation for your damages.