Vehicle damage claims can be divided into two kinds: (1) able to be repaired and (2) total loss. The law gives the insurer the prerogative on whether to fix the car or declare it a total loss. As you might have guessed, the insurer will do whatever is cheaper.
If the car is able to be repaired, you have the right to select a reputable body shop, and you are entitled to a rental car for each day your car is in the shop.
An insurance claim is a formal request by a policyholder to an insurance company for coverage or compensation for a policy event or covered loss: that’s the simple definition.
When you file an insurance claim, you are effectively requesting that the insurance company review your claim and, upon approval, provide a payout to cover your loss or damage. Unfortunately, it’s not always as simple as that, especially after an accident where you have been injured by another person’s negligence. In these cases, you need a qualified insurance claims lawyer on your side.
Some of the most common types of insurance claims are car insurance claims, health insurance claims, homeowners insurance claims, and life insurance claims.
One of the most common types of insurance claims is the auto claim, which often arises following a car accident. As many Texans know, after a car crash, filing a claim often involves dealing with two different departments within the insurance company: the property damage department and the bodily injury department.
The property damage department handles vehicle damage claims, which can be divided into two categories: repairable damage and total loss. If your car can be repaired, you usually have the right to choose a reputable repair shop of your preference, and you are often also entitled to a rental car for the duration of the repair.
But, it’s important not to overlook the possibility of your car’s diminished value after an accident. At trade-in, your car may be worth less money because of its accident history.
If the insurance company declares your car a total loss, it will pay the actual cash value, which is often determined by the lowest estimation they can find. As an insured party, it’s wise to check local dealerships and other valuation sources before accepting a total loss settlement from your insurance company. You should also contact a qualified and experienced insurance claims attorney to make sure you’re getting everything you’re entitled to.
Health insurance claims are another common type of insurance claim. These claims typically arise when an insured individual receives medical care, and the medical provider bills the insurance company for the services rendered.
Often, health insurance claims can be as straightforward as a doctor’s office billing your insurance carrier directly for a routine check-up. However, for more complicated medical procedures or treatments, especially after an accident, you may need to file a claim with the help of an insurance claims lawyer. While handling health insurance claims, it’s important to note that the insurance company’s goal is to pay as little as possible to settle the claim.
This is often achieved by insurance adjusters using a software program to scan diagnostic and procedure codes found in medical records and bills, then reducing the charges to a rate similar to what Medicare would have paid.
However, this approach has several flaws, and most healthcare providers do not offer Medicare rates to non-Medicare beneficiaries: in fact, many have a limit on how many Medicare patients they will even agree to treat regularly, since they are forced to offer artificially low prices to Medicare well below market value (often even below cost). Contact an insurance litigation lawyer right away if your health insurance company isn’t paying what they owe.
Homeowners insurance claims can be filed for various reasons, such as natural disasters, theft, or damage to personal property. When a homeowner files an insurance claim, it means they are making a formal request to their insurance provider to compensate them for a loss covered under their homeowners policy.
This could be anything from damage to the physical structure of the home to loss or damage to personal belongings. For example, if a car crash or fire caused damage to a home, the homeowner would typically file a homeowners’ insurance claim to request compensation for the necessary repairs.
Life insurance claims are fundamentally different from car, health, and homeowners insurance claims. The filing of a claim here typically occurs following the death of the policyholder. The beneficiaries of the policy file the claim to receive the death benefit. This process usually requires submitting a certified copy of the death certificate to the insurance company, along with the policy number and a completed claim form.
It’s important to note that most insurance companies have specific procedures in place to verify the claim and ensure the death benefit goes to the rightful beneficiaries. They will review the claim, the circumstances of the insured’s death, and the specifics of the policy to ensure all terms and conditions have been met. If you run into any roadblocks, don’t hesitate to contact a qualified insurance litigation attorney right away.
The insurance claim process begins when you file a claim with your insurance provider. The claim is a formal request that asks the insurance company to act on the coverage laid out in your insurance policy, or, if you’ve been injured by someone else, to act on the coverage provided to the negligent party.
Once you’ve filed the claim, an insurance adjuster from the company will evaluate your claim to determine the extent of the loss or damage.
In the case of an auto insurance claim, for instance, after a car accident, the adjuster might inspect the vehicle damage, analyze the police report, and even talk to witnesses. For a health insurance claim, the process may involve reviewing medical bills and corresponding with medical providers.
Not all claims are approved. The insurance adjuster’s job is to verify that the claim falls within the bounds of the policy. If the claim is denied, or if the payout seems insufficient, the policyholder can typically appeal the decision.
If you file an insurance claim, will it result in higher insurance premiums? While it’s not an absolute rule, this can sometimes happen.
Insurance companies use a complex algorithm that considers various factors, including the number and cost of claims a policyholder has filed. If the company’s algorithms determine that you pose a higher risk due to your claim history, your premiums may increase.
However, it’s important to note that not all claims will result in an increased premium. For instance, a claim may not cause an increase if the incident was deemed not to be your fault, or if you have chosen a policy with accident forgiveness.
Many claimants close the property damage portion of their claim without recovering money for their car’s diminished value. At trade-in your car will be worth less money because of its accident history.
If the insurer “totals” your car, it will pay “actual cash value.” To determine ACV, the insurer will resort to the source that provides the lowest amount, usually CCC. Before accepting a total loss settlement, check KBB and NADA online as well as local dealerships.
In some instances, it may not be clear who was at fault in an accident. This ambiguity can complicate the insurance claims process. Texas operates under a comparative fault system, meaning each party involved can bear a percentage of fault. Insurers will often use this system to their advantage, reducing their payout by asserting that you were more at fault than you really were.
However, these assertions on the part of an insurance company are not binding and do not carry weight in court: your degree of fault can be settled there. If the insurer claims that you were partially to blame, it’s crucial to seek legal advice. An attorney can help you defend against these allegations.
Similar to vehicle claims, the insurer’s bodily injury department has one singular mission: to pay as little as possible to settle the claim. Although insurance adjusters are not doctors, they frequently second-guess diagnostic tests run by the doctor at the emergency room of the hospital or treatment by your family doctor.
The adjuster will determine the “value” of your BI claim by using a software program that scans the diagnostic and CPT (procedure codes) found in your medical records and bills and then “reduces” the charges to what Medicare would have paid, regardless of whether you are a Medicare beneficiary.
Similar to how using CCC rendered the lowest possible car value, using Medicare as a benchmark yields the lowest possible rate for the medical charges.
This is a flawed approach for many reasons. First, many people do not have Medicare. Second, whether the insurer “reduces” the bills or not, the healthcare providers did not agree to the reductions. In fact, according to the hospital and doctors, the patient is ultimately responsible for the full amount of the bill. Third, Medicare yields the lowest rates for healthcare services because Medicare uses economies of scale to leverage the enormous buying power of the federal government to reduce the cost of the entitlement program. Using Medicare rates in the context of a car crash where there is third-party liability insurance, is not a valid basis to reduce your settlement offer.
The way a payout occurs can vary depending on the type of claim and the specifics of the insurance policy.
For instance, with an auto claim, if your vehicle can be repaired, the insurance company will typically pay the repair shop directly. However, if your car is deemed a total loss, the insurer will usually pay you the actual cash value of your vehicle before the accident occurred. This can sometimes result in disputes over the car’s value, and it may be necessary to consult local dealerships or online resources like KBB to ensure you receive a fair valuation.
For homeowners’ claims, the payment might cover the cost to repair or replace damaged personal property, and it could also include additional living expenses if you’re unable to live in your home during repairs.
When You Suffer a “Total Loss” or Can’t Afford to Pay for the Damages
A “total loss” in the context of auto insurance refers to a situation where the cost to repair a damaged vehicle exceeds its actual cash value. In such cases, the insurance company may opt to declare the vehicle a total loss and offer a payout equivalent to the car’s actual cash value before the accident.
There may also be instances where the compensation you receive from an insurance company doesn’t cover the full extent of your damages or medical bills.
In these situations, remember that you have options, including seeking legal advice to ensure you’re getting a fair deal from the insurance company.
If you receive an insurance claim payout, how you spend that money largely depends on the specifics of your claim and your policy. If your insurance company pays you directly, there may not be any stipulations on how the money must be used.
However, if your claim involves a mortgage company or a car loan, those entities could have requirements on how the money is spent, usually to repair or replace the damaged property. Your insurance litigation attorney will be able to help you keep as much of the claim money as you’re entitled to and protect you from unfair adjustments.
If someone files an insurance claim against you, it usually means that they believe you are at fault for damage or injury. Your insurance company will likely investigate the claim, which could include reviewing the accident details, examining the property damage, and potentially, speaking with any witnesses.
Your insurance company will then decide whether to accept or deny the claim based on their findings. If the claim is accepted, your insurance company will typically pay the claim up to the limit of your policy. Your insurance claims lawyer can tell you more and help you fight any false claims made against your insurance.
Related topic: What Do I Do if the Other Side’s Lawyer Calls Me?
In Texas, insurance companies have 15 days to respond to claims, though this can be increased to 45 under certain circumstances, and 35 days to settle the claim once it is filed. If a claim is approved, they have five business days to pay out.
Remember that this deadline is based on everything going smoothly, including smooth communication between you and the insurer. Otherwise, there can be delays. Your lawyer can be especially helpful here.
There are circumstances where you might be able to file a claim with two insurance companies. This typically happens when more than one insurance policy could cover the damages.
For instance, if you were in a car accident while driving a company vehicle, both your personal auto insurance policy and your employer’s insurer might be involved. Each case is unique, so it’s crucial to communicate with your insurance agent or a legal professional to understand your options.
An insurance claims lawyer assists policyholders in dealing with their insurance companies during the claims process. They can help interpret the language of insurance policies, guide clients through the complex procedures of filing a claim, and negotiate with the insurance provider for a fair settlement.
When insurance companies allege comparative fault or use strategies to devalue your claim, an insurance claims lawyer can provide invaluable assistance. For instance, they can challenge a low actual cash value offered for a total loss auto insurance claim or negotiate medical bill payments using fair market rates.
If you have further questions or need assistance with an insurance claim, contact Brian C. Gutierrez, Attorney at Law, at 979-271-5338 right away for help.
Texas has a comparative fault system, which means a plaintiff’s damages are reduced by the percentage of responsibility the plaintiff bears in causing the crash (up to 50% and after that the plaintiff’s claims are completely barred). It’s routine for many insurers to allege you were partially at-fault because it saves the insurer money. Of course, the insurer is not an honest broker when it comes to making this allegation. The good news is that even if the insurer says you were partially to blame, the claim is not binding and carries no weight in court.