What should you do if your claim is unresolved with your insurance company?

There are a number of things that can be done. I will use a hypothetical property claim (rather than a health claim) to illustrate.

1. When a claim for benefits is submitted, an insurance adjuster is assigned to handle it. Usually, the adjuster handles the claim from start to finish. That is, he/she conducts an investigation as to the facts, determines if the occurrence is one that is covered by the policy, and may request further information from you (the insured). At that point, you will have the name and phone number of the adjuster.

2. Sometimes, the adjuster is an employee of the insurance company, usually called an "in-house adjuster". However, in some cases, an insurance company delegates the claim adjusting function to "outside adjusters". These are people or firms that do the same kinds of work as inside adjusters, but who are not employees of the insurer. Instead, they have contracts with the insurer to do the adjusting work. Nonetheless, the insurance company is responsible for their actions because they are working as agents of the insurer.

3. If a claim is unresolved after a "reasonable" time, it is helpful to escalate the process to the next higher level of authority within the insurance company. "Reasonable" is a fluid term that depends upon many factors. For example, a claim for benefits that arises due to the involvement of multiple persons or entities (such as a construction defect which may involve manufacturers, suppliers, and builders), is likely to take longer to resolve than a more simple one, such as a single car auto collision. In the more complex situation, the insurer will, in addition to the tasks described in #1 have to take recorded statements, photos, and perform other tasks. It will also usually take longer to determine whether the occurrence is covered by the policy. In the meantime, you will probably have heard from the adjuster on many occasions to give status reports.

4. If you have waited a "reasonable" time (which could be weeks or months, depending upon circumstances such as complexity of the claim), and the claim is still unresolved, you may want to escalate the matter to the adjuster's supervisor. Generally, his/her identity can be found just by asking. You will need the adjuster's name and the claim number that has been assigned to your claim (found on all correspondence from the insurer). Call or write to the supervisor, politely explain the situation, and ask that he/she intervene. Usually the supervisor will do so. When the adjuster is contacted by his/her supervisor about the claim, they will normally bring your claim to the "top of the pile". This is similar to the "squeaky wheel getting the grease" theory.

You can handle the issue in a similar way if an outside adjuster is involved. This is because the insurance company is responsible for the adjuster's actions. Also, there are probably provisions in the contract between the insurer and the outside adjuster requiring that claims be resolved within a "reasonable" time. Once again, call the insurer to determine who, within the insurer, is responsible for supervising the claim. Politely explain the problem and ask for their intervention. The person within the insurance company was typically responsible for hiring the adjuster and supervising the adjustment of the claim. Therefore, he/she does not want the actions of the adjuster to reflect poorly on him/her.

5. If the claim remains unresolved, you can go to the State Insurance Regulator (although the name of the Office may differ by State). Since insurers and adjusters are regulated and licensed by the regulator, the regulator will contact the party(ies) to investigate. Your first contact with the regulator will usually be its Office of Consumer Services (or similar name), which provides intake services. The complaint is then sent to appropriate offices within the regulator's offices that handles the regulation of insurers, adjusters, or whomever else is involved. The part(ies) will have to explain to the regulator the reason for the delay. The regulator may agree or disagree with their explanation.

6. You should always enlist the help of your insurance agent if you are having difficulty with the claim. You are his/her's customer, and they will want to assist in order to keep you as a customer.

7. If all else fails, you can file a lawsuit. If so, seek an attorney that has a solid background in "insurance coverage" cases, not one who just dabbles in them. An insurance coverage case, especially if the claim has been denied by the insurer, are very complicated. Therefore the lawyer will need to be experienced in interpreting policy language and identifying facts under which to have a court determine that there exists coverage for the claim.

8. It is also important that you keep a record of all contact to and by the insurer and the adjuster, as well as all correspondence. These will be needed when you go to the insurance regulator and/or an attorney.