Insurance complaint question?

Question

When the insurance company receives a complaint from the insurance commissioner, what is the process? Are there any instances where the insurance company will reverse their decision to deny a claim? Thanks!

Answer 1

Possible, though uncommon.  The state can not tell an insurance company to pay a claim.  You two have a legal contract, and both are required to act as agreed.  If a company denies a claim your recourse is to sue.

The state looks at how the business was handled to see if there were any violations of state laws, and if they find any usually will fine the company.  Of course if they violated a law in your denial they would have to reconsider in light of the violated law.

Answer 2

Prior poster is correct with his response.  When the claims department receives the complaint, usually from their Home Office, a supervisor or manager responds to the complaint.  The file is reviewed.  If appropriate the decision will be overturned.  I overturned a decision maybe once or twice only because I felt the liability decision was incorrect.   Since most coverage denials do come from examiners in Home Office,  and the denials are sometimes also reviewed by coverage attorneys, it is not likely a denial of coverage will be overturned.  You will probably have to sue your insurer.  But who knows, each insurance company is different.