Having a claim and going to insurance can be desperate, right?

The normal thing is to feel overwhelmed by circumstances, especially if at the first change they tell you that they do not take charge of its consequences. You look at the policy and you don’t understand how they can tell you that it doesn’t have coverage.

You look on the Internet and all you find are complaints.

Everything seems very complicated. You don’t know where to start or what the priority is, or even if the resolution is worth discussing.

However, not claiming what you consider to be yours causes discontent to grow in you. You think it is unfair but you do not see yourself with the capacity to manage the situation.

You would like someone to tell you what to do, how, and when, right?

You are not alone, I dare tell you that I know the way to act.

Therefore, this article is dedicated to what you can do when you are not satisfied with the resolution that the company has given to the claim.

1. How does the insurer act upon learning of the claim?

Before, I am going to tell you, briefly, what are the steps that an insurer takes when it becomes aware of the claim. This chronology, standard for most, is undergoing some changes that you should be aware of.

You have had an accident and you have communicated it to the insurer through your insurance broker or directly. From that moment on, a whole process is triggered that begins with:

1.1 Receipt of the claim declaration

The first step begins with the declaration that you have to make to the insurer once the claim has occurred. In it you must inform it in detail of the causes, circumstances, and consequences, known to you, that derive from it.

There are other channels through which the insurer can find out the occurrence of the claim, but will come to you to confirm it.

1.2 Opening of the file

Upon receipt of the declaration, the insurer will open a claim file to which it will incorporate all the information obtained during its processing.

1.3 The first checks and initial assessment of the claim

At the time the file is opened, the company makes a first check of whether or not the causes that motivate the claim are covered by the policy. Depending on its result, the insurer will adopt any of these decisions:

  • Refuse the consequences of the loss if it is not covered in the policy.
  • If there is clear coverage and enough information to indemnify the insured, he will indemnify him and archive the file.
  • If it is a complex claim or the necessary and sufficient information does not exist, the processing will continue.

In either case, the company will make a first assessment of the cost of the claim and reserve the estimated amount.

1.4 The intervention of the expert

The task of investigating, analyzing the possible causes of the loss, and assessing its consequences is entrusted by the insurer to the expert.

The expert is a professional expert in the matter under analysis and the acceptance of the claim by the company will depend on him.

1.5 Resolution of the claim

The last step, once the investigations are concluded and the claim has been assessed, will necessarily happen because of the insurer:

Pay the corresponding compensation or benefit. Once paid, the insurer may terminate the contract by voluntary decision or because the insured risk has ceased to exist as a result of the loss.

Deny payment of compensation. In this case, the insurer must inform the insured of the reasons for his decision, providing the evidence to verify it.

2. What do I do if I don’t agree with the resolution?

In recent times, insurers are replacing the “field” expert with more or less specialized teams of claims processors who resolve as if they were an expert.

The decisions they make, generally based on the information and documentation provided by the insured, are causing an increase in the number of rejected claims. They often lack the necessary evidence to adopt them and are carried out in the confidence that the insured will not claim.

The law establishes that the insurer must compensate the insured at the end of the investigations and expert opinions necessary to establish the existence of the claim and assess its consequences. And it establishes a period of 40 days, from the date of the claim, to make the payment of the minimum known amount.

If you agree with the established compensation, you only have to charge.

And if you are not, the next step is to carry out an expert opinion contradictory to that of the insurer.

3. The contradictory expert opinion in the claim to the insurer

If you do not reach an agreement with the insurer, within the period indicated above, you may appoint an expert to make a contradictory expert opinion.

You must inform the insurer of the appointment of the chosen professional. This will have a period of 8 days to designate yours. If I did not do so, I would be obliged to accept the opinion of your expert.

Once the experts are appointed and you accept the appointments, several results can be given:

That there is an agreement between the experts. In that case, the expert opinion will become a joint record stating: the causes of the loss, the assessment of the damage, and all those circumstances that influence the determination of compensation. It must also state the liquid amount of the compensation.

There are many claims where the insured gives up due to exhaustion or for not entering into legal claims for their cost. Also due to ignorance of their right to make an expert opinion on the part.

In my opinion, the only way you have to combat the dominant position of the insurer is by pulling legislation. And there it is to make use of the appointment of an expert by the insured.

But before going any further, I want to give you a good recommendation and that is that if you need to consult an expert.

And now, we are going to continue with the article that you still have things to know.

4. The appointment of the third expert

But it may happen that both experts do not reach an agreement, what to do in that case?

The solution is to appoint a third conformity expert between both parties. If there is no agreement on the appointment, you can promote a file as provided in the Law of Voluntary Jurisdiction.

Once the appointment is accepted, together with the other two experts, they will proceed to prepare a report that will be approved by unanimity or majority. This expert opinion is binding on the parties, without prejudice to the fact that it may be challenged in court. The insurer has 30 days to challenge it, while the insured has 180 days from notification.

If the report is contested, the insurer has 30 days to pay the insured the minimum amount referred to in art. 18 of the LCS. If the expert opinion is not contested, the amount determined by the experts will be paid within a period of five days.

5. The last step, the judicial claim

Sometimes it is better to go, after the resolution of the insurer, to court. In that case, you will have to use the evidence to try to make the company see reason.

The claim will be followed through a verbal trial in the courts of your domicile. When acting without a lawyer, the plaintiff will formulate a succinct demand in which he will state the data and circumstances that concur, will identify the defendant, fix precisely what he asks for, and will prove it documentary.

At this point, when you claim compensation from the insurer, it is essential to have a legitimate expert opinion that supports your claims.

The success of your claim increases if the opinion is defended before the judge by an expert. That is why I advise you to have the experience and knowledge of NPA to improve your position with the insurance company.

Conclusions

I have told you how the insurer acts when the occurrence of the claim is notified. And as it is more and more frequent that you find yourself with the refusal of its consequences. There are several reasons, but all of them justified in the knowledge that the majority will not be discussed by the insured.

The expert opinion by the insured’s expert is becoming increasingly necessary. Resorting to the second or third appraisal is a right guaranteed by article 38 of the LCS.

But you can also go to court, where having a good expert opinion is essential.

And if you wonder who pays the expenses, I will tell you that it will depend on the medium you use. But in most cases, your expert’s fees can be paid by your own insurer.

I can’t resist asking you:

How many times have you given up claiming the insurance after refusing the claim?

Don’t you think it is time to start discussing the resolutions of the insurance company without fear?

Leave your answers in the comments.

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