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What is the Procedure for Challenging a Claim Denial in Florida?

Thu May 31st, 2018 on     Insurance Claims,    

In Florida, insurance policyholders are not required to accept the original determination of their insurer — for example, the denial of a submitted disability insurance claim, or an unusually low benefits payout.  Policyholders are entitled to dispute such decisions.

Depending on your insurance policy, there may be an internal appeals procedure that you’re required to follow in order to dispute your insurer’s adverse determinations.  Some policies allow for third-party review without having to go through the internal appeals procedure, however.  In any case, certain policyholders will have to exhaust their administrative appeals options before they are entitled to sue and recover damages pursuant to the traditional litigation process.

Resubmitting a Claim

Before you move through the appeals process, you’ll want to consider the possibility of gathering additional documentary evidence of your various covered losses and resubmitting your claim.  In many cases, the insurer will simply deny an otherwise legitimate claim on the basis of insufficient evidence.

Internal Appeals Process

If your insurer makes an adverse determination — for example, if they deny your claim for benefits, or significantly undervalue the benefits to which you’re entitled — then you may appeal their determination internally.

The procedure for appealing an adverse determination varies considerably depending on the type of insurance involved, the insurance company, and the specific language of your insurance agreement.  For example, your property insurance policy may require that you to meet with a third-party appraisal specialist before moving through the appeals process.  Others may require that you utilize an appraiser hand-picked by the insurance company.

Though there is no internal appeals procedure that effectively applies to all insurers in the state of Florida, you’ll — as a general rule — have to submit your appeal with the insurer, giving them proper notice of your intent to challenge their determination.  You’ll also have to submit all the necessary documentary evidence that supports your claim.

These internal appeals processes are usually time-limited and must be resolved within a few months (at most).  Depending on the situation that you find yourself in, however, you may be eligible for an expedited appeals process.  For example, if your house has burned to the ground in a fire, then you may be eligible for an expedited appeals process due to the emergency nature of the situation.

Traditional Litigation

Once you’ve gone through the appeals process, you may want to litigate (though it’s worth noting that some policies do not actually require that policyholders move through the appeals process before bringing an action in court).  Litigation is often necessary, especially in cases where the insurer has engaged in “serious misconduct” and has thus given you the potential basis for a bad faith claim.

Your willingness to litigate will — to some degree — put pressure on the insurer to negotiate a settlement, or to simply accept your original claim.  In Florida, insurers are on-the-hook for your attorneys’ fees if they “lose” in litigation.

Speak to an Experienced Miami Insurance Coverage Lawyer for Assistance

Ver Ploeg & Marino, P.A., is a Miami-based firm that has spent over two decades representing policyholder-clients in a range of insurance disputes, from disability insurance to health insurance to business interruption insurance, and more.

We are committed to client-oriented, comprehensive legal representation.  We keep the lines of communication open so that our clients understand exactly how their case is proceeding — and why.  Further, we are thoroughly prepared for litigation, which gives us a competitive edge early in the process.  Over the years, this approach has allowed us to secure significant wins on behalf of our clients.

Call (305) 577-3996 or submit an online form to schedule an appointment with an experienced Miami insurance coverage lawyer here at Ver Ploeg & Marino, P.A.

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