Your roof leaked and caused $15,000 in water damage. You filed a claim, expecting your insurance to cover it. Instead, you got a denial letter with vague language about policy exclusions. You've paid premiums religiously for a decade, and now when you need it, they won't pay. This happens thousands of times daily, but understanding why claims get denied gives you leverage to fight back.
The most common denial: "maintenance issue, not sudden damage." Your roof leaked because shingles deteriorated over time. The insurer argues you should have maintained the roof, so the damage is your fault. They're not entirely wrong - policies cover sudden, accidental damage, not gradual wear and tear. But the line between the two gets fuzzy fast, and adjusters err toward denials to save the company money.
Second reason: late reporting. Policies require "prompt" notice of damage. What's prompt? They don't say. Some people wait weeks to file while assessing damage. The insurer claims you violated the policy by waiting too long. This defense often fails on appeal - "prompt" is subjective, and documented reasons for delay (waiting for contractor assessment, evacuation, etc.) usually win appeals.
How to appeal: Start by requesting the full claim file and the specific policy language they're citing. Adjusters sometimes misinterpret policy terms or apply exclusions that don't fit. Get a public adjuster to review it - they work for you, not the insurer, and know every trick companies use to deny claims. Public adjusters typically take 10-15% of what they recover, but they often double or triple the payout.
If the internal appeal fails, file a complaint with your state insurance commissioner. Insurers hate these complaints - they get audited, fined, and scrutinized. Commissioners often force reconsideration of denied claims. Finally, consider hiring an attorney who specializes in insurance bad faith. If the denial is clearly wrong and the insurer is stonewalling, bad faith lawsuits can result in the original claim amount plus punitive damages.