Detailed Answer
This guide explains, in plain language, what typically happens after you submit an insurance claim in California and what rights and options you have. This is general information only and does not take the place of legal advice. If your claim is large, denied, or involves potential bad faith, consider contacting an attorney.
Disclaimer: This is not legal advice. It is educational information about California law and common claim procedures.
1. Acknowledgment and claim opening
After you file a claim, the insurer usually opens a claim file and assigns a claim number and an adjuster or examiner. The insurer should acknowledge receipt and begin communication. California law prohibits unfair claim settlement practices by insurers; see California Insurance Code § 790.03 for examples of prohibited conduct, such as unreasonable delays or denials: Cal. Ins. Code § 790.03.
2. Assignment to an adjuster and initial contact
An adjuster will contact you to gather basic facts, explain next steps, and request supporting documents (police report, photos, medical records, receipts, proof of ownership, etc.). Keep copies of everything you send and take notes of phone conversations (date, time, who you spoke with, and key points).
3. Investigation
The insurer investigates the claim. That can include inspecting property or a vehicle, reviewing medical records, interviewing witnesses, and reviewing policy terms. The adjuster will evaluate whether the loss is covered under your policy and what damages are reasonably payable.
4. Requests for information and proof of loss
Insurers commonly ask for a “proof of loss” or additional documentation. Respond promptly and in writing. Do not ignore requests — failure to provide reasonable information can slow or jeopardize your claim.
5. Coverage decision: acceptance, partial payment, or denial
After investigating, the insurer will either:
- Accept the claim and make a payment;
- Partially pay if some items are covered and others are not; or
- Deny the claim. A denial should explain the reason and cite relevant policy provisions.
If the insurer denies coverage or liability, it should state the factual and legal bases for the denial. If you disagree, request a written explanation and copies of any reports the insurer relied on.
6. Evaluation of damages and appraisal
For property claims, the insurer will estimate repair or replacement costs. Some policies include an appraisal clause that lets you and the insurer each pick an appraiser and, if needed, an umpire to resolve the amount in dispute. Review your policy for appraisal or arbitration clauses and follow any required steps and timelines.
7. Negotiation and settlement
You and the insurer may negotiate a settlement amount. If you agree, the insurer typically asks you to sign a release and then issues payment. Read any release carefully: it may waive future claims related to this loss.
8. Disputes, denials, and escalation
If you disagree with the insurer’s handling, you have options:
- Ask the insurer for a written explanation and documentation supporting its decision.
- Use policy dispute processes such as appraisal or internal review, if available.
- File a complaint with the California Department of Insurance (DOI). The DOI reviews consumer complaints and can take administrative action against insurers for unfair practices. Start at the DOI website: California Department of Insurance.
- Consider mediation or arbitration if allowed by your policy.
- If the insurer unreasonably denies or delays payment without a legitimate basis, you may have a legal claim (including potential bad faith). Speak with an attorney promptly to protect your rights.
9. Payment and closing the claim
When the insurer pays, it will typically issue a check or electronic payment and mark the claim closed. If you accept payment, confirm whether the insurer will remain responsible for any additional related costs that surface later.
10. When you might need an attorney
Consider legal help if the insurer denies a valid claim, delays payment unreasonably, makes a low-ball offer, or asks you to sign a broad release before you know the full extent of your losses. California law outlaws unfair settlement practices by insurers; you may have claims beyond the insurance contract in some cases. An attorney can explain potential remedies and deadlines.
Helpful Hints
- Document everything. Keep photos, receipts, repair estimates, medical bills, and a written timeline of what happened.
- Communicate in writing when possible. Email and certified mail create a record you can use if there is a dispute.
- Don’t sign a final release until you are sure the payment covers all current and reasonably anticipated losses.
- Preserve evidence. Don’t throw away damaged property until an adjuster inspects it or you get written permission to dispose of it.
- Beware of deadlines. Policies and law may limit how long you have to file suit or demand appraisal. If the claim is important, consult an attorney early to preserve rights.
- Be cautious on social media. Insurers sometimes review public posts to contest claims.
- If you suspect unfair treatment, read Cal. Ins. Code § 790.03 on unfair settlement practices: https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=790.03&lawCode=INS.
- If you need help filing a complaint or learning your rights, visit the California Department of Insurance at https://www.insurance.ca.gov.
Every claim is different. This article explains commonly followed steps and California legal protections, but it cannot cover specific outcomes for a particular case. If your claim is complex, denied, or substantial, consider speaking with a licensed California attorney for tailored legal advice.