Claim Disputes With Your Own Insurance Company

Unfortunately, some insurance companies believe the job of the insurance adjuster is not to pay you the maximum value of your claim - it's to save the insurance company money. As friendly as they may be, these adjusters are not on your side, and they are not trying to help you – in reality they are trying to “help” you keep the insurance company’s profits high.
If you believe an insurance company is withholding benefits properly due you or is guilty of unfair claim settlement practices, contact us for a free, no obligation consultation. We are here to do everything we can to help our clients get the answers, the assistance, and the compensation that they are entitled to under the law when the client is involved in a dispute with the client’s own insurance company.

We handle cases involving claim disputes with insurance companies all over the DFW Metroplex and surrounding cities, including Dallas, Fort Worth, Arlington, Denton, Burleson, Cleburne, Decatur, Weatherford, Haltom City, North Richland Hills, Richland Hills, Azle, Mineral Wells, Sherman, and Denison.

We will meet with you at our office or any location convenient to you.

Evening and weekend appointments are available.
The following pages of detailed legal information will give you insights into the depth of our capabilities in insurance bad faith cases.

Example Case Handled By Our Law Firm - Disputed Underinsured Motorist Coverage Claim
Our client, a physically active, tall, healthy owner of a construction company in business just a few months, was in a motor vehicle accident where the police investigation determined that the other driver was totally at fault.

For unknown reasons, the other driver’s car swerved out of the northbound lane of highway 121, crossed over the grassy median separating northbound and southbound traffic, and hit our client’s vehicle head-on (his pickup was heading south on 121). Even though wearing a seat belt, his head hit the top of his pickup during the head-on collision because the collision buckled the floor of his pickup upward, pushing his seat, head and body in an upward direction.

He directed traffic after the accident and declined medical care when offered it at the scene by emergency medical personnel. He assumed his injuries were minor “whiplash” injuries and would heal on their own.

Within a few days he began suffering short-term memory loss, anxiety attacks, severe depression, and recurring accident event flashbacks. He began to dread going to sleep and avoided it as long as possible each night.

His construction company failed financially because he could not remember job schedules and verbal commitments made to customers and suppliers, simple tasks that he had done successfully for years as the general manager of a large corporations’ remodeling division. This short-term memory loss caused job cost overruns, lost profits, and dissatisfied customers.

Expert neurological, psychiatric, and neuropsychological evaluations determined that he had sustained traumatic brain injury and post-traumatic stress syndrome requiring extensive psychiatric care and medication for more than two years. At one time he was reduced to painting houses by himself because his company no longer had any employees.

The liability insurance carrier for the driver-at-fault for the accident, a young woman with no assets, settled for policy limits after suit was filed. We then made a claim on our client’s auto policy for underinsured motorist coverage (UIM) with two different auto insurance companies because he had a company policy and a personal policy with this coverage. Each of the two policies had six figures in UIM coverage. The two insurance companies then offered much less than policy limits for the UIM claim.

Because our client believed his losses were far greater than the insurance company offers, we sued the two insurance companies for the UIM coverages available and for bad faith, deceptive trade practices, and failure to timely pay the underinsured motorist claim.

The judge abated the bad faith, deceptive trade practices, and failure to timely pay the UIM claim. The judge also ruled that Mr. Rodgers could not try the second case, the bad faith, deceptive trade practices, and failure to timely pay claims, because he was a witness to the insurance companies’ bad faith actions and would need to testify in that trial. A lawyer cannot be a liability witness in a case he is also trying because it would likely confuse the jury. The first case then went to trial on the issues of whether our client was also at fault for the accident and the total amount of his damages.

The insurance defense lawyers were confident that a local jury would not award compensation in line with his losses because he was never admitted to a hospital and “there was never a band aid on him,” thus he obviously could not have been seriously injured in the accident and was exaggerating his damages to “win the litigation lottery.”

The trial judge refused to allow evidence of the financial losses our client sustained while trying to keep his company going after the accident because, since the company was new and therefore without a history of profitability, it was “too speculative” to allow a jury to decide what his construction company would have earned had he not been injured in the accident. The Jury was only allowed to consider his medical bills, physical pain, and physical/mental impairment from the head injury.

After a six day trial, the jury returned a verdict in our client’s favor for an amount that was three times the combined amount of the best offer made by the two insurance companies.

The jury verdict was upheld by the appellate courts after the insurance company appealed the results two times – once on the issue that the jury’s six figure award for physical/mental impairment was excessive and once on the issue that the interest on the verdict as awarded by the trial judge was excessive. (JP130R)

Overview of Cases Involving Claim Disputes With Your Own Insurance Company

Many Texans pay their insurance premiums faithfully, year after year remaining loyal to their insurance company. Then, when a claim is finally made for a loss, they are shocked when it is denied or the claim process is made unreasonably difficult by the insurance company. Improper claim denial includes the practice of offering an unreasonably low amount to settle a claim when the insured has proven a much higher loss amount.

Historically, some insurance companies have acted to limit payouts on claims by inadequately investigating claims, delaying investigations, failing to pay or delaying payment of valid claims, treating the insureds as adversaries, misrepresenting or concealing facts, or showing a pattern of denying all claims. They apparently believe these tactics will ultimately wear down the insured so that the insured will take less than fair value to settle the claim.

Texas insurance companies have a duty of good faith and fair dealing in their actions toward their own policy holders. This means an insurance company is required to pay or deny your claim within a reasonable period of time, respond to your inquiries in a prompt manner, cooperate with you with regard to resolving your claim, and provide written notification of the reasons why it is reducing or not paying your claim.

Failure to act in good faith allows the policyholder to sue the insurance company for “insurance bad faith" for failing to follow the requirements of the Texas Insurance Code, including failing to timely pay the policyholder’s claim, and for acting in ways forbidden by the Texas Deceptive Trade Practices Act.

This ability to sue the insurance company directly only applies to the person who actually purchased the insurance policy from the insurance company, such as the person who purchased a homeowners policy, auto liability policy, disability policy, or a commercial insurance policy.

Bad faith usually occurs in two types of circumstances. First, if you have a claim and payment is owed to you, but the insurer refuses to pay in full or delays without a good reason, bad faith may exist. Secondly, if a claim for money damages is made against you, the insurance company carrying your liability insurance for your auto or home may owe you a legal defense and should pay any damages rightfully owed to the suing party. If your insurer unreasonably fails to protect you, bad faith may exist.
Some examples of typical bad faith claims include the following:
Home Owners Insurance – your insurance company refuses to pay benefits due you for fire or hail damage to the structure of the home or loss of contents within the home or refuses to fairly and properly protect you if you are sued by someone who was injured while at your home.

Disability Insurance – Disability insurers often have a practice of denying payments after payments have been made for two years. Other insurers deny payment by relying on medical evidence prepared by the insurance company's own in-house medical staff, while ignoring the opinions of your treating physicians.
Other examples of "bad faith" insurance practices by insurance companies include:
1. Misrepresenting a material fact or policy provision to the policyholder about the policyholder’s insurance coverage.
2. Failing to provide promptly to a policyholder a reasonable explanation of the basis in the policy supporting the insurer's denial of a claim or the offer of a compromise settlement of a claim.
3. Failing to acknowledge and act reasonably and promptly upon notice of the policyholder’s claim.
4. Failing to adopt and implement reasonable standards for the prompt investigation of the claim.
5. Refusing to pay a claim without conducting a reasonable investigation.
6. Failing to confirm or deny coverage of a claim within a reasonable time after the proof of loss statement has been completed by the policyholder.
7. Failing to attempt in good faith to make a prompt, fair and equitable settlement of a claim in which liability has become reasonably clear.
8. Failing to promptly settle a claim where liability has become reasonably clear under one portion of the insurance policy coverage in order to get the policyholder to accept a lower settlement amount under other portions of the insurance policy coverage.
Group Health Insurance Claim Denials
Group health insurance claim denials are under different rules. If your health insurance policy was purchased through your employer or provided as part of your employee benefit package, federal ERISA law may apply. If so, you may be required to work within your insurance company's internal appeal process, including any strict deadlines, before you can file suit. Read the section at the bottom of this page for more information.
Follow these rules in dealing with your insurance company:
1. Read your policy – it is a contract between you and the insurance company. Don't rely on your agent to tell you what your policy covers. Read it to understand your policy's coverages and exclusions.
2. Read the “Consumer Bill of Rights.” Insurance companies must include the "Consumer Bill of Rights" with personal automobile, homeowners, and credit life policies or renewals. It explains your rights and responsibilities.
3. Put everything in writing that you provide the insurance company and keep a copy for your records.
4. Request the insurance company to put everything in writing.
5. Ask the company to identify the specific language in the policy that covers your claim and any denial.
6. Write down information about your telephone and in-person contacts, including the date, the name and title of the person you spoke with, and what was said.
7. Keep a record of your time and expenses spent making the claim.
Should you need to ultimately hire a lawyer to force the insurance company to pay your insurance claim, the information listed above will help the lawyer get up to speed very quickly on your case.
Losing the Right to Sue For Insurance Bad Faith/Unfair Claim Settlement Practices
You must file your insurance bad faith or unfair claim settlement practices lawsuit within a certain time period or else you will lose your right to pursue your claim. In many cases, the suit must be filed within two years from the date of the accident.

Simply contacting the insurance company is not enough to stop the running of the two year period.
There are other reasons to act quickly. Key witnesses may disappear, witnesses’ memories may fade, and vital documents may be lost. It is crucially important that you do not delay in consulting with an attorney.

Contact us for a free no-obligation consultation as soon as possible to ensure that you retain your right to pursue your claim.
Contact Us for a Second Opinion If Another Attorney Has Declined To Represent You
Attorneys regularly decide whether the case that they are reviewing does or does not meet all the requirements to be a viable, sound case. Making this determination is not an exact science. Based on different experiences and analytic abilities, one attorney may turn down the opportunity to represent a client and another attorney may shortly thereafter decide to take the case.

The second reviewing attorney saw something the first reviewing attorney may have overlooked.

We would welcome the opportunity to review your insurance claim even if another attorney has turned the case down. There is no charge or obligation for our review.
You may contact us at the following phone numbers at any time:

Office: toll free: 1-866-560-1075

local: 817-717-4080
Group Health Insurance Claim Denials Explained In Detail (2007)
If your Texas health insurer or health maintenance organization (HMO) refuses to pay for a treatment because it considers the treatment medically unnecessary or inappropriate, you may be able to have an Independent Review Organization (IRO) review the decision.
IROs are independent third parties certified by the Texas Department of Insurance (TDI) to review the medical necessity and appropriateness of health care services provided or proposed to patients. The IRO’s decision is binding on the health care plan, which pays for the review.
Independent review is available if (1) Texas law requires your health care plan to participate, or the plan voluntarily participates, in the IRO process, (2) your plan or its utilization review agent (URA) determines that a treatment recommended, but not yet performed, is medically unnecessary or inappropriate, (3) your plan or its URA determines that an ongoing treatment is medically unnecessary or inappropriate.
A health care plan must base its denial on written screening criteria established and updated with involvement by practicing physicians and other providers.
In most cases, you must use the health care plan’s internal appeal process before requesting an IRO review. You can bypass the appeal process, if you or your doctor believes your condition is life threatening. Call your insurer or HMO to learn about its appeal process.
Independent review is not available if:
1. your health care plan refuses to pay for a service the plan doesn’t cover, such as cosmetic surgery.
2. you received treatment before the plan determined that the treatment was not medically necessary or appropriate. This is considered a retrospective review of medical necessity.
3. your health care plan is not required by law to participate in the IRO process. For example, Medicaid and Medicare, including Medicare HMO plans, and certain other health plans are not required to participate in the IRO process. Contact your health plan to find out if it is required to participate in the IRO process.
If your plan isn’t required to participate in the IRO process, you, your doctor, or another provider may file a complaint or appeal about the denial of health care or the denial of payment for health care already performed. Ask your health care plan or employer about its complaint or appeal process.
You, your representative, or your provider may request an independent review. Only you or your legal guardian, however, may sign a medical records release form allowing the IRO to access documents relevant to the review.
The first step is to secure an appeal and independent review request form from your health care plan. Your plan must provide the form if it is required to participate in the IRO process and it denied a treatment because it regarded the treatment as medically unnecessary or inappropriate. You can bypass the appeal process if you or your doctor believes your condition is life threatening.
Your health care plan or its URA must give you the independent review request form again after denying an appeal. If you want an independent review, complete the form and return it to the health plan or URA. Contact the Texas Department of Insurance (TDI) if you believe your insurer or HMO failed to inform you of your rights.
The health plan or URA must immediately notify TDI of your request for an IRO review. TDI will assign your case to an IRO within one business day after receiving your request and notify all parties of the IRO assignment. TDI makes IRO assignments between 7 a.m. and 6 p.m., Central time, Monday through Friday, except holidays.
The health plan or URA must send the IRO the information and medical records needed for its review. The IRO must receive the information within three business days from the date of the review request. The IRO must reach a decision within 15 days after receiving the necessary information but no later than 20 days after the IRO receives its assignment. In cases involving life-threatening conditions, the IRO must reach a decision within five days after receiving the necessary information but no later than eight days after the IRO receives its assignment.
Your insurer or HMO must pay for treatments the IRO decides are medically necessary or appropriate. The IRO will provide you with a notice of its decision that includes:
1. the clinical basis for the decision.
2. the screening criteria used to make the decision.
3. a list of qualifications of the IRO staff who reviewed your case.
4. a statement certifying that the provider reviewing the case doesn’t have a conflict of interest with the treating provider or any of the providers who previously reviewed the case.
5. a certification by the IRO that the reviewing physician or provider has certified that no known conflicts of interest exist between the provider and any of the treating physicians or providers or any of the physicians or providers who reviewed the case for determination prior to referral.
Copyright 1994 - 2007 Clifford B. Rodgers.
Last Modified July 6, 2007.