File a claim can be frustrating. Maybe you’re waiting for an update that’s not yet here, or expecting a check, and instead got a list of questions. From outside, you can feel like nothing is happening. But behind the scenes, many moving parts (file reviews, coverage checks, vendor assignments, internal approvals) can slow the process down.
Insurance is one of the most regulated industries. The adjuster cannot be configured simply by creating rules. Claims are governed by state laws and regulations, many of which are based on national guidelines such as the Unfair Claim Settlement Practices Act (UCSPA). These rules exist to ensure fair treatment.
As a former coordinator, I worked under these rules. As an expert witness hired by an attorney in a bad faith lawsuit, I use them to determine whether the carrier violates standard claim processing procedures. Here are some of the most important things – and how do they protect you as a consumer?
Rule #1: The adjuster should explain the policy to you
Insurance contracts are complicated, but the adjuster must interpret and explain them accurately. While policyholders are expected to read and understand their reports, coordinators are trained to monitor you for what is and is not covered by your policy. This includes clarifying how approvals, exclusions, and restrictions apply to you Specific claims.
Why this rule is important: Insurance contracts can be difficult to interpret, even for seasoned experts. The adjusters are hoped to help fill that gap not only for transparency, but also to avoid confusion that could delay claims or lead to unforeseen denials. You should also let us know if additional damages or conditions may be covered by your policy.
This rule applies to first-party claims, including your own policies. In most states, third-party claimants (such as someone submitting to your liability coverage) are not entitled to the details of the insurance contract unless a lawsuit is filed.
From the field: Even the most skilled experts can make mistakes, but all the mistakes that the adjuster makes in his interpretation of policy become a matter of maliciousness and frequency. As an expert witness, I have seen dozens of claim files in which the adjuster failed to clearly explain coverage. When that happens, misunderstanding and mistrust grow. And there is also the possibility of conflict.
For example, in a Homeowner Insurance Contractthere are additional coverage options (additional money) such as debris removal and increased construction costs. If this coverage is paid, it is currently a hot topic in the insurance industry. However, if policyholders are not notified when and how to obtain these additional funds, they lack the full benefit of their policy.
Rule #2: The adjuster must respond to your claim within a reasonable time frame
Once you file a claim, the clock will start to click. In many states, insurance companies have 10 and 15 days to accept your claim and start an investigation. This includes responding to emails, answering questions, and requesting documents in a timely manner.
Why this rule is important: Your time The house is damaged Or your car is in the store, two weeks can feel forever. State regulations are in place to keep the process running and ensure that claimants are not waiting without a response. These timelines are not uniform – vary by state and sometimes the decisions of the courts setting the standard rather than the Department of Insurance.
Even if there is no specific day count written in the law, many states resort to broader requirements. Insurance companies are to respond and act within a “reasonable” timeline. That is a legal term. It is rooted in what ordinary people think is acceptable in the circumstances. What is reasonable after a fender bender is not the same as what is reasonable after a complete loss due to a fire. But in all cases, it reflects the expectations that the industry and the courts have from carriers and coordinators alike.
From the field: Most delays are not driven by bad intentions. Often, it’s as easy as adjusters can’t set up a diary – reminders – and the claims fall off their radar. Within six weeks, we checked files that the adjuster had not touched. The adjuster had an estimate of damages. He had to review it, apply coverage and ban it Exclusionissue payment. In the diary system, we found that the adjuster deleted the notes to follow up the estimate. The adjuster forgot to add a new diary to confirm estimates, coverage and issuance payments.
Rule #3: Insurance companies must communicate in writing why they are denying their claims
In your case Claims will be rejectedinsurers must provide written explanations for the reasons and refer to the specific policy language that supports rejection. This is a specific legal requirement in almost every state. Some people require that the denial letters dispute the decision or include a specific language about contacting the state’s Department of Insurance.
Why this rule is important: Insurance contracts are full of densely specialized languages. If the claim is rejected, vague explanations like “not covered” will not cut it. Insurance companies should point out some of the policies that support decisions. That transparency helps you decide what to do next.
From the field: I worked as an expert witness in a lawsuit that was denied for “wear and tears.” That exclusion is common, but so are exceptions when the resulting damage is due to a sudden, accidental event, when that damage is covered. I reviewed the denial and immediately flagged the exception not being considered. After the lawyer saw it, the case took a very different direction. That written explanation – and what it left behind was key to challenging the decision.
What if your claim is not progressing as expected?
Not all disagreements with the adjuster means that shade is occurring. The delay can be due to volume, misunderstanding, or simple monitoring. This can be corrected to suit the clarity.
For example, I contacted the insured for a claim for cannabis theft. For months I was looking for documents. When it finally arrived, the receipts were vague, general, continuous, written in the same pen. I had no last name, phone number or email address. This was a sign of fraud. I informed the insured who intended to report him to the fraud department. He didn’t want to give me any information because he was afraid to betray his trust with the cannabis farmer. Once I understood why the insured weren’t cooperating, I was able to process the payment. The delay was on me, but it was not cheating. If I slowed down and listened, it could have been misunderstood.
Unfortunately, not all billing issues can be resolved with better communication. If your process doesn’t match the expected timeline or you’re struggling to get a clear answer, here are the steps:
- Document everything: Save emails, take notes while you call, get things in writing as much as possible.
- Please ask for a copy of the claim file: Some states allow you to request a claim file containing notes, photos and communications. This helps you better understand what is happening in the claim and take action if you think it’s wrong.
- Escalates to the supervisor: If you hit a wall, ask (just politely, but firmly) and talk to someone higher.
- Please contact your state’s health department: Every state has an agency that investigates complaints. In many cases, you can file a complaint online.
- Talk to an expert: A public coordinator or lawyer may be useful if your claim is big or particularly complicated.
Conclusion
These regulations may sometimes feel procedural or bureaucratic, but they exist to protect you. Careers must follow certain rules and mistakes occur, but these rules set a baseline for fairness and accountability.
Not all violations are malicious acts. The adjuster is human and causes an error. However, if the violation is repeated, intentionally or with neglect from the insured, it may have a legal consequence. Understanding your rights and standard coordinators will help you defend yourself and find the difference between delays and true mistreatment.
