Appeal insurance denial
In cases where the insurance company refuses to pay insurance indemnity for damages, you can submit an objection before the insurer itself. Contact an insurance law professional to prepare the objection to the denial.
Obligations of the insured person
Upon the occurrence of an insured event, the insured is subject to obligations set out in the Insurance Code. He must notify the insurer of the occurrence of the event, keep the damaged property for inspection by the insurer. With respect to its claim, the insured has to submit all documents specified in the insurance contract or additionally requested by the insurer in order for the insurer to decide on the claim. In addition, the claim must specify the bank account of the insured.
Obligations of the insurer
According to the Insurance Code, the insurer is obliged to register the date of the claim, as well as the date of subsequent receipt of each document under it. Within 45 days of reception of the claim, the insurer may request other documents in connection to the claim that are not specified in the insurance contract or its internal rules.
The deadline for payment of compensation upon the occurrence of an insured event cannot be longer than 15 days after the claim has been filed with the insurer or after all evidence specified in the insurance contract or additionally requested by the insurer has been presented. Within this 15-days term the insurer may also issue a justified refusal to pay compensation.
The insurer must either make the payment or make a justified refusal to make this payment within this 15 days term.
In cases where not all documents, provided in the insurance contract or the internal rules of the insurer, are presented by the insured, the term for the insurer's decision is extended to:
- 6 months for accident, illness, car insurance, property insurance, and medical expenses;
- 3 months for Third party liability of motorists.
When the insurer can refuse to pay
The insurer has the right to refuse payment of compensation in the following cases:
- if the damage was intentionally caused by the insured person;
- if the insured person has not fulfilled obligations under the insurance contract that is significant in view of the insurer's interest, has been provided for by law or in the insurance contract, and has led to the occurrence of the insured event;
- in other cases provided by the Insurance Code.
Therefore not every violation of contractual obligation can be a ground for refusing to pay the insurance indemnity. That is why consultation with insurance specialists is in your interest.
In order not to pay or to pay less compensation, the insurer must prove that the given failure to fulfill an obligation under the contract is significant or caused the occurrence of the insured event.
What does justified refusal mean?
The reasons for the refusal are very important for the rights of the insured. In practice, however, it is done with a few standard sentences from insurers. For example, a discrepancy between the damages found during the inspection compared to those specified in the claim for payment of compensation or the mechanism for the occurrence of the event, without specifying anything specific.
Preparing to appeal the denial decision
First of all, consulting with a lawyer specializing in insurance cases will help you determine whether, in the given situation, it is justified to file an objection to the refusal with the insurer itself or directly to file a claim to the court.
In addition, the general terms and conditions of the insurance, what risks are covered and what are excluded, should be reviewed again very carefully, and whether there is a failure by you, as insured, to fulfill a significant for the insurer obligation.
Insurance law is peculiar, and therefore only a competent lawyer will determine whether there is indeed a violation of your rights on behalf of the insurer by refusing to pay compensation, as well as how you can protect them.
Deadline for response from the insurer when submitting a claim for reconsideration of the refusal
When you file an objection (complaint) with the insurer to review the refusal to pay compensation, within 7 days the insurer must provide you with the factual and legal justification of the determined amount of compensation.
This article has been prepared for the purposes of general information only and does not constitute legal advice with respect to any particular subject or situation. For specific legal advice you should contact an attorney-at-law. Stoeva, Tchompalov & Znepolski is not responsible for any legal action undertaken on the basis of the information contained herein.