Detailed Answer
This article explains, in plain language, what typically happens when an insurance company denies an injury claim after a minor motor-vehicle accident in South Carolina and what steps you can take next. This is educational information only and not legal advice—consult an attorney for advice about your situation.
Typical factual example
Hypothetical: You are in a low-speed rear-end collision. You feel neck pain and see your doctor. Your insurer denies your injury claim, saying the medical records show a pre-existing condition and the symptoms are not related to the crash. Below are the practical steps to appeal that denial and protect your rights in South Carolina.
1. Read the denial and your insurance policy carefully
When you receive a denial letter, it should state the reason(s) for denial and cite the policy provisions relied on. Common denial reasons include: (a) lack of coverage, (b) policy exclusions, (c) late notice, (d) medical records not showing causation, or (e) suspected misrepresentation.
Why this matters: The insurer’s stated reason determines what evidence you need to gather (e.g., medical records, photos, witness statements, repair estimates).
2. Preserve and gather evidence
- Keep the denial letter, claim number, adjuster correspondence, and all policy documents.
- Get copies of all relevant medical records, emergency-room notes, imaging reports, and bills that show treatment and dates.
- Collect photos from the scene, repair estimates, witness contact information, and any accident report.
- Document ongoing symptoms with a contemporaneous journal (dates, symptoms, how they affect daily life).
3. File an internal appeal with the insurer
Most insurers have an internal appeal or review process. Submit a concise, written appeal that:
- References the claim number and the denial letter.
- Explains why the denial is incorrect, pointing to specific medical records, treatment dates, or policy language.
- Attaches supporting documents (medical records, physician letters discussing causation, photos, police report).
- Requests a written decision and gives reasonable time for review (e.g., 30 days).
4. Consider a physician’s declaration on causation
If the denial turns on causation (insurer says your injuries are pre-existing), ask your treating physician to provide a short written opinion linking the symptoms to the accident and explaining how the treatment resulted from the crash.
5. Use the South Carolina Department of Insurance if needed
If your appeal to the insurer does not resolve the dispute, you can file a complaint with the South Carolina Department of Insurance (DOI). The DOI can investigate consumer complaints, identify unfair practices, and sometimes help by asking the insurer to reconsider. To learn more or to file a complaint, see the DOI consumer page: https://doi.sc.gov/consumer/file-complaint.
6. Determine if alternative dispute resolution applies
Some policies contain arbitration or appraisal clauses that require disputes to go to mediation, appraisal (usually for property), or arbitration. Review your policy for any clause that forces arbitration and note the timelines and procedures it requires.
7. Know the time limit to file a lawsuit in South Carolina
If you must sue the insurer (for breach of contract or other claims), don’t miss the state statute of limitations. South Carolina generally requires that actions for personal injury or property damage be brought within three years. See South Carolina’s statute of limitations for personal injury and property claims: S.C. Code Ann. Title 15, Chapter 3. Missing the deadline can bar your lawsuit even if the claim is valid.
8. Possible legal claims and remedies
If the denial is unlawful, potential remedies may include:
- Contract damages—payment under the policy for covered benefits (medical bills, lost wages, etc.).
- Additional damages—under certain circumstances you might have an extra-contractual claim (e.g., bad-faith practices) depending on the facts and law—consult an attorney.
- Administrative remedies—the DOI complaint process described above.
9. When to get an attorney
Consider hiring a lawyer when:
- The insurer denies coverage but your damages are meaningful (medical bills, lost work).
- Causation is disputed and you need an expert medical opinion.
- The insurer delays, fails to investigate, or appears to act unfairly.
- You face a short deadline or an arbitration clause that requires legal steps.
An attorney can review your policy, collect evidence, write an effective appeal, negotiate with the insurer, and file suit if necessary.
10. Practical timeline for a straightforward appeal
While timelines vary, a common path looks like this:
- Days 0–30: Gather records and send a written appeal to the insurer.
- Days 30–90: Insurer reviews and either reverses the denial, requests more information, or upholds the denial.
- After 90 days: Consider DOI complaint, mediation, or talk to a lawyer about court or arbitration options.
Each case differs; insurers vary in how fast they respond.
Important statutory and administrative resources
- South Carolina Department of Insurance consumer complaint page: https://doi.sc.gov/consumer/file-complaint.
- South Carolina statutes on limitations for personal injury and property claims (generally three years): S.C. Code Ann. Title 15, Chapter 3.
Bottom line: Start an internal appeal quickly, collect objective supporting evidence (medical records, physician statements, photos, accident report), consider filing a complaint with the South Carolina DOI if the insurer stalls, and do not miss the state limitation period if you intend to sue.
Helpful Hints
- Respond in writing and keep copies of everything you send and receive.
- Send important correspondence by certified mail or email with delivery/read receipts.
- Ask treating doctors to explain how the crash caused or worsened your injury—insurance adjusters rely heavily on physician statements.
- Get an early legal check-up: many attorneys offer free or low-cost consultations for denied claims.
- Don’t sign releases or broad statements without reading them and, if in doubt, talking to a lawyer.
- If the insurer cites “late notice,” show when you reported the crash (police report, call log, email).
- Keep a clear timeline (dates of accident, medical visits, communications with insurer) to simplify appeals or litigation.
- File a DOI complaint if the insurer’s conduct looks unfair or if internal appeals fail: https://doi.sc.gov/consumer/file-complaint.
- Remember the likely three-year statute of limitations for personal injury/property claims in South Carolina—act early. See: S.C. Code Ann. Title 15, Chapter 3.
Disclaimer: This information is educational and general. It does not constitute legal advice, create an attorney-client relationship, or substitute for advice from a qualified South Carolina attorney who understands the details of your case.