Insurance Litigation: How to Fight a Denied or Disputed Claim

Insurance litigation arises across every line of coverage. Life insurance disputes arise when a beneficiary's claim is denied based on a contestability clause. Health insurance litigation arises when an insurer refuses to authorize treatment or denies a claim as not medically necessary. Disability insurance litigation arises when a long-term disability carrier terminates benefits based on an independent medical examination. Insurance claims litigation is a broad field, but the legal principles that govern insurer conduct apply consistently across all lines of coverage.

Insurance dispute counsel evaluates the specific type of insurance dispute and the applicable legal framework governing the insurer's conduct, identifies the coverage arguments, bad faith theories, and regulatory remedies available in the policyholder's state, and advises on the litigation strategy appropriate to the claim type and the insurer's conduct.

Insurers must acknowledge a claim within defined timeframes, investigate, and issue a coverage determination. The duty to investigate requires the insurer to conduct a reasonable inquiry into the facts. An insurer who denies a claim without conducting a reasonable investigation has acted in bad faith regardless of whether the denial is ultimately justified. Delay violations expose the insurer to statutory penalty interest and bad faith liability.

Insurance payout counsel evaluates the insurer's claim handling conduct against applicable state insurance code requirements, identifies delay violations and failure-to-investigate claims that create statutory penalty exposure, and advises on the regulatory complaint process through the state insurance department when the insurer has violated state insurance code claim handling requirements.

Life insurance litigation arises from contestability disputes, lapse insurance policy disputes, and beneficiary disputes. When a policyholder changes beneficiaries late in life or the designation was procured by undue influence, disputes follow. The contestability period is typically two years, after which the insurer's right to challenge the policy on misrepresentation grounds is significantly limited. A life insurer that fails to provide required lapse notices creates extracontractual liability.

Death benefit insurance counsel pursues life insurance claims on behalf of beneficiaries whose claims have been denied under contestability clauses or lapse provisions, evaluates the insurer's compliance with required grace period and lapse notice statutes, and advises on the litigation strategy for competing beneficiary claims when multiple parties assert entitlement to death benefit proceeds.

An insurer who believes there were material misrepresentations may rescind the policy rather than pay the claim. Policyholders contesting rescission have several defenses. The misrepresentation may not have been material. The insurer may have waived the right to rescind by accepting premiums after learning the facts. An insurer who rescinds a policy without adequate basis faces bad faith liability.

Insurance misrepresentation counsel challenges insurance policy rescission on behalf of policyholders and beneficiaries, evaluates the materiality and reliance elements of the insurer's rescission claim, and advises on the bad faith exposure the insurer faces when rescission is used as a pretext to avoid paying a legitimate claim.

First-party bad faith arises when the insurer unreasonably denies or delays payment of the policyholder's claim. Third-party bad faith arises when the insurer fails to settle within limits and the policyholder faces an excess judgment. Extracontractual damages in a first-party bad faith case include consequential damages, attorney fees, and emotional distress. Punitive damages are available in most states where the insurer's conduct was malicious, oppressive, or fraudulent.

Insurance fraud counsel evaluates first-party and third-party bad faith claims against insurers, advises on the extracontractual damages available when an insurer's denial was unreasonable, and pursues punitive damages on behalf of policyholders when the insurer's conduct was malicious, oppressive, or carried out with conscious disregard of the policyholder's rights.

Workers' compensation insurance disputes arise over claim acceptance, medical treatment authorization, and indemnity benefit calculation. Disability insurance litigation governed by ERISA applies when the disability plan is employer-sponsored. Non-ERISA disability disputes are governed by state contract and bad faith law. Independent medical examinations conducted at the insurer's request are a standard feature of disability disputes, and the objectivity of these IME examinations is frequently challenged in litigation.

Industrial accident insurance counsel pursues disability and industrial accident insurance claims on behalf of injured workers and policyholders, challenges independent medical examination findings that fail to reflect the policyholder's actual functional limitations, and advises on the specific procedural requirements for disability insurance litigation in both the ERISA and non-ERISA context.

A claims handling expert is essential in insurance bad faith litigation. Class action insurance claims require expert testimony that the insurer violated its own guidelines or conducted an inadequate investigation. Settlement valuation requires an honest assessment of the policy benefit, extracontractual damages, and the strength of the bad faith evidence. Trial strategy must frame insurer misconduct through specific internal documents accessible to a jury.

Workers' compensation counsel manages the discovery and claims file production process in insurance litigation, retains claims handling and medical experts to build the coverage and bad faith case, and advises on the use of insurance regulatory materials as evidence of the standard of care applicable to the insurer's conduct.

Jurors may be skeptical that an insurance company acted wrongfully. Framing the case around specific internal documents, specific adjuster statements, and specific violations of the insurer's own guidelines gives jurors concrete evidence on which to base a verdict. The strength of the claims file evidence of deliberate misconduct affects settlement leverage significantly. Cases with strong evidence of intentional misconduct and a sympathetic plaintiff command far higher settlement values.

Health insurance fraud counsel evaluates insurance class action claims against insurers whose systemic misconduct has affected large numbers of policyholders, advises on the settlement value of individual and class insurance litigation claims, and develops trial strategy that frames insurer misconduct through specific internal documents and guideline violations accessible to a jury.