What can an insurance company ask for when deciding what to pay for in a claim?

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What can an insurance company ask for when deciding what to pay for in a claim?

My son was involved in an auto accident on 12/11/18. I have been haggling with the insurance company since January. I have sent them all documents they have asked for, bills, a letter stipulating my son’s losses, tangible and intangible, etc. The latest is they asked for a doctor’s letter verifying my son needed to be off for six weeks due to a concussion sustained in the accident. I provided that. After a week and a half of phone tag I called and left two voicemails with no reponse-they later claimed I didn’t leave a phone number but I did, the adjuster said the letter wasn’t enough because it didn’t say WHY my son was off it didn’t state the reason….yet the adjustor had not asked for it to state this. Now they want all his medical records from the doctor visits with diagnosis. My question is am I legally bound to provide those? Can they deny the claim altogether if I don’t? We are haggling over the lost wages at this point…the pain and continuing mental suffering they are causing with their delays will be another discussion.

Asked on March 29, 2019 under Accident Law, Missouri

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 3 years ago | Contributor

Yes, they can ask for this--an insurer may ask for any materials they feel necessary to prove the existence or extent or validity of a claim. Medical records with diasnosis is reasonable when you are claiming for lost wages from an inability to work--they can seek documentation or evidence to prove the inabiltiy to work. If you don't provide what they want, they can deny the claim.
If they deny the claim, you do have the right to sue. If the insurer is your son's own insurer and you are claiming under his own policy, you'd sue the insurer for breach of contact--for violating their contractual obligation (an insurance policy is a contract) to pay the claim. 
On the other hand, if the insurer you are describing is the other driver's insurer, you would sue the other driver, not the insurer: the insurer, not being your son's insurer, has no duty or obligation directly to him, and the other driver, not the insurer, is the one who injured your son. If you can prove in court that the other driver was "at fault" in causing the accident--driving negligently or carelessly--then your son can get a judgment ordering the other driver to pay for injuries, at which point, either the other driver and/or the other driver's insurer (whose obligation is to pay for their driver when he is found by a court to be at fault) should pay. Bear in mind that the other driver (and so also his insurer) only is liable to pay when the other driver was at fault.


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