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Claim Denials

Module 4, Lesson 2

What to Do When Claims Get Denied

Don't Panic

A denial isn't necessarily the end.

Many denials can be reversed with the right approach
Understand WHY the denial happened
Address the specific issue

Common Denial Reason #1

Coverage Exclusion

The carrier claims the damage isn't covered under the policy.

How to Respond:

Get the denial in writing with specific policy language. Evaluate if their interpretation is correct. If the facts were misunderstood, demonstrate the actual cause of loss.

Common Denial Reason #2

Late Notice

The carrier claims the homeowner didn't report the loss in time.

How to Respond:

Document the actual timeline. When did the loss occur? When was it discovered? When was it reported? Courts often find "prompt notice" is flexible with good reason.

Common Denial Reason #3

Failure to Mitigate

The carrier claims reasonable steps weren't taken to prevent additional damage.

How to Respond:

Document what mitigation steps were taken and when. Your call-out for emergency mitigation is evidence. Explain any delays.

Common Denial Reason #4

Pre-Existing Damage

The carrier claims the damage existed before the reported loss.

How to Respond:

Provide timeline evidence. Before photos if available. Documentation of the loss event. Expert opinions if necessary. The burden should be on the carrier.

The Appeal Process

Request the denial in writing with specific reasons
Review carefully—identify what needs to be addressed
Gather evidence that addresses their concerns

The Appeal Process (Continued)

Submit a formal written appeal with evidence
Follow up persistently (Day 3, Day 7)
If appeal denied, consider escalation options

Escalation Options

Request appraisal (if available under policy)
File complaint with state insurance commissioner
Consult with an attorney about legal options
Involve the homeowner—they have more leverage

The claim is the homeowner's claim. They can file complaints directly.

When Denials Stick

Sometimes despite your best efforts, the carrier refuses to pay.

Homeowner may be willing to pay out of pocket
Consider legal action for large claims
Your contract should specify homeowner responsibility if insurance denies
Learn from the experience—prevent future issues

Preventing Denials

Document the loss event clearly—photos of water still present, moisture readings
Document the timeline precisely—when loss occurred, discovered, reported
Identify the water source definitively—source determines coverage
Keep copies of everything—for potential disputes or litigation

Coming Up Next

Lesson 4.3: Supplements

Adding scope discovered during the job
Documentation at discovery
The 5-step supplement process
Common supplement scenarios

✓

End of Lesson 4.2

Claim Denials

See you in the next lesson!