What to Expect When You’re Expecting To Make An Insurance Claim – A Cheat Sheet
This cheat sheet lists some issues you may want to consider when making an insurance claim. It tells you (1) essential information you need; (2) your basic rights; and (3) helpful “best practices.” Please note this is only a summary and may omit details relevant to your specific circumstances.
Basic Information You NeedFirst, make sure you have the entire insurance policy. The policy is critical because it states your coverage, your rights, and the insurer's rights. It likely includes provisions requiring you to take certain action - like notifying your insurer of a claim within a certain period of time - in order to preserve your rights. Many people are surprised to learn that their declarations page, summary plan description, or brochure explaining their coverage isn't the policy. An insurance policy virtually always consists of a collection of multiple separate documents. For instance, a life insurance policy might consist of an application, a policy contract, and several addenda, riders or attachments. There are often additional documents such as annual statements that are also critical to understanding your rights under the policy.
Second, note whether you obtained your policy through your employer. Insurance policies you acquired through or in connection with your employer are different from regular policies. Employer-related policies are subject to a federal law called the Employee Retirement Income Security Act (ERISA for short). ERISA can apply even if the policy was issued by an insurance company that's not your employer, and even if your employer doesn't pay your premium. ERISA is very different from the law governing normal insurance policies; it's complex and imposes special rules and deadlines. If you think your policy might be subject to ERISA, it's important to pay extra close attention and consult a qualified attorney.
Third, it's also critical to make sure you know all the facts. Obtain all the documents that are potentially relevant. If it's a health or disability claim, have all the relevant medical records. If it's a car crash, have the police report.
Know Your RightsFirst, you have the right to be treated fairly. Washington law imposes a duty on insurers to act in "good faith." Good faith generally means the insurer must treat you honestly, made decisions on your claim based on adequate information, and never put their interests over yours. Remember that policyholders also have to act in good faith, so be sure you're always honest when dealing with your insurer.
Second, you have the right to insist the insurer follow the policy. The policy is a contract between you and the insurer. The insurer has to follow it. The insurer can't try to re-write the policy after you make a claim.
Third, you have the right to prompt claim responses. Washington law requires your insurer to respond to your claim within a specific time - often ten days - and acknowledge that they received your claim. Beyond the initial claim, insurers generally have to respond to your communications about the claim in a reasonable time. The insurer must also tell you whether or not they will pay the claim within a reasonable time after you provide the documentation they need to made a decision.
Fourth, you have the right to a full investigation of your claim. Insurers have to decide whether to pay claims based on a reasonable investigation. That means your insurer has to make a reasonable effort to look for evidence that's relevant to your claim. They can't just consider the evidence that supports denying the claim.
Best PracticesFirst, keep a paper trail. Make sure you document everything that's relevant to the policy or your claim. It's especially critical to document all your communications with the insurer or with third parties (doctors, mechanics, potential witnesses, etc.). Communicate via email or hard copy mail when practical. If you have a phone call or in-person meeting with an adjuster, take notes, then send them an email summarizing your understanding of the discussion and inviting them to correct you if they think you got it wrong. If you lose money or have other harm because your insurer isn't doing what they're supposed to, document it. If it's not on paper, it never happened.
Second, cooperate with reasonable requests. If your insurer makes a reasonable request for information or similar assistance with your claim, comply promptly. Remember you have a duty to act in good faith, and your policy may affirmatively require you to cooperate in making a claim. That doesn't mean bending over backwards, but you should comply with reasonable requests. If you wind up in court, you want to be sure that it's your insurer and not you who the judge sees as being unreasonable.
Third, be proactive. Procrastination will never improve your position and it can make you lose your rights entirely if you miss a deadline. Promptly notify your insurer if you think you have a claim. Include as much information about the claim as possible. Follow up with the adjuster if they are slow in getting back to you. Reach out to third parties who might have relevant information. Generally, delay in processing your claim benefits your insurer - not you.