Insurance Claim Denied? What to Do Next in Pennsylvania
What a denial letter has to tell you, how to ask your insurance company to look again, how to file a complaint with the Pennsylvania Insurance Department, and the two deadlines that can end a claim.
A denied insurance claim isn't the end of the claim, and what to do next starts with the letter in your hand. In Pennsylvania a denial has to be in writing, and if the company is relying on a provision, condition or exclusion in your policy, the letter has to refer to the one it's using.
So read that part of your policy first, then write back and ask the company to look at the claim again, and if the answer doesn't change, take it to the Pennsylvania Insurance Department. If you want a local starting point, we keep a page of insurance agents for Berks County.
What the denial letter has to tell you.
A denial comes to you in writing, and the company can't deny a claim on the grounds of a policy provision, condition or exclusion unless the denial refers to that provision. So the letter names the piece of your policy the decision rests on. Find it and read it.
Read past the line the letter quotes, because what's printed under an exclusion can decide as much as the exclusion does. The standard homeowners form does that in one spot, where the wear and tear list is followed immediately by an exception for certain accidental water discharge from a pipe or an appliance, narrowed by conditions of its own. Your own policy governs, and its wording may differ, so read yours.
What a policy covers and leaves out is its own subject, and we've written separately on what a homeowners policy does and doesn't pay for and what a roof replacement costs here.
Asking the company to look at the claim again.
On a property claim, Pennsylvania doesn't give you a legal right to an internal appeal. The claims rules don't set up a procedure and they don't set a deadline for asking, so you haven't missed a step there. You can write to the company's claim manager and ask to have the claim looked at again, and whether they run a process for that is up to them.
Auto is different in one spot: if an auto insurer refused a medical bill after a peer review determination, you're one of the parties who can ask for that determination to be reconsidered, and the request has to be made within 30 days of it.
Put it in writing. A letter or an email gives you a copy of what you asked and when, and it's the same packet you'll upload if the next step is a complaint, so send the photos, estimates and receipts.
Three things the company can't do are worth knowing, and each comes up only if the company does that thing, so skip the ones that aren't yours. It can't deny the claim because you didn't show the property, unless it can prove it asked and you refused. If it offers you a release to sign, it can't ask for one that reaches beyond what the payment was for. And if a check arrives for part of the damage, it can't put language on that check releasing it from the rest of what it owes, so a partial payment doesn't close the rest.
How to file a complaint with the Pennsylvania Insurance Department.
Complaints go to the Insurance Department through its Consumer Services Online portal, and you file it yourself: create an account, submit the complaint, upload your documents, then message the investigator assigned to you and read what goes in the file. The complaint ID number you get back is your receipt. File once, and put anything new in the comment section instead of filing again, which is what the Department asks.
The consumer line is 1-877-881-6388, and pressing 3 and holding reaches an investigator. Documents can also go by mail to the Pennsylvania Insurance Department, Bureau of Consumer Services, 1209 Strawberry Square, Harrisburg, PA 17120, with your complaint ID on them. Our page of insurance agents covers the county if you want a local name to talk it over.
Once the Department sends your company an inquiry about the claim, the company has 15 working days to give an adequate response.
Which deadlines matter, and what each one is counted from.
Two of these clocks are yours, and they don't work the same way. The hard one is the suit condition: on the standard homeowners form, you can't bring an action against the company unless you've complied with the policy's Section I terms and the action is started within two years after the date of loss.
A signed, sworn proof of loss is one of those terms and the second clock: the statement of what you lost on the form the company gives you, due within 60 days after the company asks for it, counted from the request, not from the day of the damage. Being late with it doesn't forfeit the claim by itself; what matters is whether the delay costs the company something, so send it promptly. If you're not sure whether the company has asked for one, put that question in the letter you're already writing.
The rest belong to the company, and since they start in different places, here they are with what each is counted from.
| What has to happen | By when | Counted from |
|---|---|---|
| You send the company your signed, sworn proof of loss | 60 days | The day the company asks you for it |
| You start a court action against the company | 2 years | The date of loss |
| The company acknowledges your claim | 10 working days | The day it's notified of the claim |
| The company gives you the claim forms, the instructions and reasonable help | 10 working days | The day it's notified of the claim |
| The company finishes investigating, or writes to say why it needs longer and when to expect a decision | 30 days | The day it's notified of the claim |
| The company writes again with the reason it still needs more time | Every 45 days | The 30-day mark, then every 45 days after it |
| The company tells you it accepts the claim, denies it, or needs more time and why | 15 working days | The day it receives your signed, sworn proof of loss |
| The company answers an inquiry from the Pennsylvania Insurance Department | 15 working days | The day it receives the inquiry |
The rows that start with you are the ones to put on your calendar, because the two-year one is the only deadline here that can end a claim on its own. The company's rows are minimum standards the Department holds insurers to, so a missed one is worth putting in your complaint, not something that decides your claim by itself.
What a public adjuster does, and when a lawyer comes in.
A public adjuster works for you instead of the company, has to hold a Pennsylvania license, and works under a written contract on a form the Insurance Department approves, for a percentage of what the insurer pays, taken out of that payment rather than added on top. The state sets no limit on that percentage. You have at least three calendar days after everyone signs to cancel, and the contract prints the date you can cancel by, so go by that date. Hiring one isn't required for the company to pay a claim.
A public adjuster can't act on an auto property damage or personal injury claim, and works for you only against your own insurance company. One who's also a contractor has to keep the two jobs apart, with two separate contracts, one function at a time, and no repair work started until the company has decided the claim.
A lawyer is a different road, and the difference is what a court can add. Under Pennsylvania's bad faith statute, a court that finds an insurer acted in bad faith toward the insured may award interest at prime plus 3 percent running from the date you made the claim, along with punitive damages, court costs and attorney fees. We're not lawyers and none of this is legal advice, so if that's your road, start with finding a lawyer in Berks County.
A health insurance denial runs on a different track.
If the letter came from a health plan, the process is different and has a deadline you can miss. Medicare and Medicaid run on their own routes: with Medicare you start at Medicare.gov, and with Medicaid or CHIP it's the External Grievance Review Process through your managed care organization.
Otherwise you go through the plan's own internal appeal first, which produces a Final Adverse Benefit Determination Letter. From the date on that letter you have four months to ask the Insurance Department for an Independent External Review. A request for a service the plan doesn't cover at all isn't eligible. It costs you nothing, doctors and other health care professionals outside the plan decide it, and their decision binds the plan.
Tonight's moves are small ones. Find the part of the policy the letter names, read it, and send your request to the claim manager in writing. If the answer comes back the same, the portal and the phone number above are next.
Common questions about denied claims in Pennsylvania.
How long do you have to act after a denied homeowners claim?
The two-year figure comes from the policy's own condition on bringing a court action, which also requires that you've met the policy's Section I terms, counted from the date of loss. It isn't a deadline for asking the company to look again or for filing with the Insurance Department, because neither of those has one. The 60 days for a signed, sworn proof of loss runs from the day the company asks for it, and being late with it matters if the delay costs the company something.
Do you need a public adjuster to get a claim paid?
No, hiring one isn't required for the company to pay a claim. A public adjuster works the claim for you under a written contract for a percentage of what the insurer pays, and can't take an auto property damage or personal injury claim.
What if the denial came from a health plan?
Finish the plan's internal appeal, keep the Final Adverse Benefit Determination Letter it produces, then you have four months from that letter's date to ask the Insurance Department for an Independent External Review. A request for a service the plan doesn't cover at all isn't eligible, Medicare and Medicaid have their own routes, and it costs you nothing.
Sources
- 31 Pa. Code § 146.7, "Standards for prompt, fair and equitable settlements applicable to insurers": a denial in writing that refers to the provision it rests on, the 15 working days after proof of loss, and the notice when more time is needed.
- 31 Pa. Code § 146.5, "Failure to acknowledge pertinent communications": the 10 working days to acknowledge a claim and to supply forms and assistance, and the 15 working days to answer a Department inquiry.
- 31 Pa. Code § 146.6, "Standards for prompt investigation of claims": the 30 days to complete an investigation and the written explanation every 45 days after that.
- 31 Pa. Code § 146.4, "Misrepresentation of policy provisions": proof of demand and refusal before a denial for not showing the property, the limit on releases, the rule on partial-payment checks, and that a missed notice or proof-of-loss time limit counts only where it prejudices the insurer.
- Pennsylvania Insurance Department, "Complaints, Questions, Help": the Consumer Services Online portal as the route to file, and the 1-877-881-6388 consumer line.
- Pennsylvania Insurance Department, Consumer Services Portal FAQ: what the portal does, the complaint ID, the mailing address for documents, and the request not to file twice.
- Pennsylvania Insurance Department, "Natural Disaster Insurance Guide": that you may take a denial to the company's claim manager.
- 75 Pa. C.S. § 1797, "Customary charges for treatment": the request to reconsider a peer review determination, and the 30 days to make it.
- Act 21 of 2012, the Public Adjuster Law (63 P.S. §§ 1601-1608): the license requirement, the written contract on a Department-approved form, the three calendar days to rescind, the fee coming out of the claim payment, and the bar on auto property damage and personal injury claims.
- Pennsylvania Insurance Department, "Public Adjusters": that hiring one is not required for a claim to be paid, and the two-contract rule for an adjuster who is also a contractor.
- Pennsylvania Insurance Department, "Request a review if your health insurance denied a treatment, medication, or service": the internal appeal first, the Final Adverse Benefit Determination Letter, the four months to request an Independent External Review, that it costs the consumer nothing, the Medicare and Medicaid routes, and that a service the plan does not cover at all is not eligible.
- 42 Pa. C.S. § 8371, "Actions on insurance policies": what a court may award where it finds an insurer acted in bad faith.
- ISO form HO 00 03 05 11, Homeowners 3 Special Form, as filed with the Nevada Division of Insurance (PDF): the two conditions on bringing an action, the proof of loss due 60 days after the company's request, the duties preamble conditioning forfeiture on prejudice, and the exception printed under the wear and tear list.