Mark A. SteinbergInsurance Laws For many people, insurance companies exist simply to provide peace of mind. People pay their monthly premiums for car insurance, home insurance, or life insurance and hope that they never have to be in a position where they need help from their insurer. However, the peace of mind comes in from the idea that should an accident and injury—or even death—occur, the insurance company will step in to help.
Unfortunately, it’s a regular occurrence for people with insurance policies to find that when the time comes, the insurance company decides it doesn’t have to provide coverage after all, despite regular monthly payments from a customer. This can be a confusing, vulnerable situation for people, which unethical insurers sometimes rely on.
Of course, there are valid reasons for an insurance company to refuse to pay a claim or even demand repayment of a claim that’s already been paid. Insurance fraud, especially in injuries, happens all over the world. People have successfully fooled insurance companies into paying out for false injuries, so these insurers are often paranoid about paying out for a false claim. However, in other instances, a legitimate accident victim may find that an insurer has decided not to honor a claim despite a real and painful injury. Sometimes, this is even for deliberate, malevolent reasons and may involve deception or distortion of facts and records to avoid paying a legitimate claim.
Intimidation Tactics
Insurance companies have years of experience dealing with their own policies and deciding when to honor a claim and when to refuse it. Unfortunately, that doesn’t always translate to the correct or ethical decision, and sometimes insurers exploit their position. They know, for example, that most people have little legal experience, especially with lawsuits. They also know that most Americans don’t necessarily have the “financial war chest” required to wage a long, drawn-out legal battle against a big corporation with an army of lawyers. Because of these factors, some less ethical decision-makers at insurance companies know that if they put enough pressure on someone complaining about a denial, the sheer legal force arrayed against such a person may make them buckle under.
However, just because an insurance company decides to deny a claim, that doesn’t mean the decision is final. And just because an insurance company has a significant legal mechanism buttressing it doesn’t mean that a win in court is guaranteed.
Experienced attorneys can help claim denials in various areas, such as personal injury, workers compensation, and even social security disability insurance. In some cases, such as with a personal injury or wrongful death claims, they work on a contingency fee, only collecting payment for legal services if they win the case or negotiate a settlement. Once an insurance company knows that someone has legal representation and even a willingness to go to court, the public nature of such a lawsuit is often something they would like to avoid, and negotiations—or even out-of-court settlements—can begin.
And of course, if it goes to court, you know you have an attorney in your corner.
A claim may or may not occur during the term of a policy. Even when the contingency covered under the policy does occur, the amount of the claim may be the full sum insured or less and in some cases, the amount may not be known for quite some time in the future.
This is a primary principle of insurance. According to this principle, you have to disclose all the information that is related to the risk, to the insurance company truthfully. You must not hide any facts that can have an effect on the policy from the insurer.
The basic concept of insurance is that one party, the insurer, will guarantee payment for an uncertain future event. Meanwhile, another party, the insured or the policyholder, pays a smaller premium to the insurer in exchange for that protection on that uncertain future occurrence.
After the insurance company receives your completed proof of claim forms and all the required supporting documents, it must decide on your claim within 40 days. After settling your claim, the insurance company must make a final payment within 30 days if it approves your claim.
Three main types of uncertainty have been identified by Klir and Yuan [1]: Fuzziness, discord, and nonspecificity, the latter two being unified under the term ambiguity ( Fig. 1).
In the insurance world there are six basic principles that must be met, ie insurable interest, Utmost good faith, proximate cause, indemnity, subrogation and contribution.
Insurance is a means of protection from financial loss in which, in exchange for a fee, a party agrees to compensate another party in the event of a certain loss, damage, or injury. It is a form of risk management, primarily used to protect against the risk of a contingent or uncertain loss.
In the insurance world there are six basic principles that must be met, ie insurable interest, Utmost good faith, proximate cause, indemnity, subrogation and contribution. The right to insure arising out of a financial relationship, between the insured to the insured and legally recognized.
Once a claim has been reported, the adjuster will begin the second step in the claims process: investigation. The first step in this process completed by the adjuster is to determine whether coverage is applicable to a loss. The methodology they use depends on whether the claim is first-party or third-party in nature.
As the final step in a claim investigation, the report highlights the most compelling facts of the case. The investigator does not typically offer an opinion in these reports; only the facts and findings.
Upon concluding the investigation, the claims adjuster will give a recommendation to the insurance company whether or not to approve your claim. While the insurance company can choose not to follow the adjuster's recommendation, the two decisions usually align.
uncertainty, doubt, dubiety, skepticism, suspicion, mistrust mean lack of sureness about someone or something. uncertainty may range from a falling short of certainty to an almost complete lack of conviction or knowledge especially about an outcome or result.
The lack of certainty, a state of limited knowledge where it is impossible to exactly describe the existing state, a future outcome, or more than one possible outcome.
The uncertainty of a measuring instrument is estimated as plus or minus (±) half the smallest scale division. For a thermometer with a mark at every 1.0°C, the uncertainty is ± 0.5°C. This means that if a student reads a value from this thermometer as 24.0°C, they could give the result as 24.0°C ± 0.5°C.
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Mark A. SteinbergInsurance Laws For many people, insurance companies exist simply to provide peace of mind. People pay their monthly premiums for car insurance, home insurance, or life insurance and hope that they never have to be in a position where they need help from their insurer. However, the peace of mind comes in from the idea that should an accident and injury—or even death—occur, the insurance company will step in to help.