How to Appeal an Insurance Claim Denial in Georgia

Receiving a denial letter from an insurance company is frustrating, especially when you are dealing with injuries and mounting bills from a car accident. But a denial is not the final word. Insurance companies deny claims for many reasons — some legitimate, many not — and Georgia law provides several avenues for challenging a wrongful denial.

This guide explains why claims get denied, how to appeal effectively, and what options you have if the appeal fails.

Common Reasons Insurance Claims Are Denied

Policy Exclusions

The insurer argues that your loss falls under a specific exclusion in the policy. Policy exclusions must be clearly stated and reasonably interpreted. Insurers sometimes stretch exclusion language beyond its intended scope to deny legitimate claims.

Disputed Liability

The insurer claims their policyholder was not at fault for the accident, or that you share enough fault to bar recovery. Under Georgia’s modified comparative negligence rule (O.C.G.A. § 51-12-33), if you are assigned 50% or more fault, your claim is barred.

Lapsed Coverage

The insurer says the at-fault driver’s policy was not in force at the time of the accident due to non-payment or other reasons. If coverage lapsed, you may need to pursue a claim under your own uninsured motorist coverage.

Late Reporting

Many policies require prompt notice of an accident. If the accident was reported late, the insurer may argue it was prejudiced by the delay and deny the claim.

Pre-Existing Conditions

The insurer argues your injuries existed before the accident. While pre-existing conditions are relevant, the eggshell plaintiff doctrine under Georgia law means the at-fault party must take you as they find you — including any pre-existing vulnerabilities.

Disputed Medical Necessity

The insurer challenges whether your medical treatment was necessary, excessive, or related to the accident.

Alleged Fraud or Misrepresentation

The insurer accuses you of providing false information — on your application, in your claim, or in a recorded statement.

Step 1: Understand the Denial

When your claim is denied, the insurer must provide a written explanation. Georgia’s Unfair Claims Settlement Practices Act (O.C.G.A. § 33-6-34) requires insurers to provide “a reasonable explanation of the basis in the insurance policy… for the denial of a claim.”

Read the denial letter carefully and identify:

• The specific reason(s) for the denial
• Which policy provision or exclusion the insurer cites
• What evidence the insurer relied on
• Any deadlines for appeal

If the denial letter is vague or does not provide a clear reason, request a detailed written explanation. You are entitled to understand exactly why your claim was denied.

Step 2: Review Your Policy

Obtain a complete copy of the insurance policy (not just the declarations page). Review the relevant coverage provisions, exclusions, conditions, and definitions. Compare the insurer’s stated reason for denial against the actual policy language.

Insurance policies are contracts of adhesion — meaning the insurer drafted them. Under Georgia law, ambiguous policy language is interpreted in favor of the insured. If the denial relies on an ambiguous exclusion, you may have grounds to challenge it.

Step 3: Gather Supporting Evidence

Build your case for the appeal by collecting:

• Medical records and bills linking your injuries to the accident
• Doctor’s statements supporting the necessity and accident-relatedness of your treatment
• The police report documenting fault
• Witness statements corroborating your account
• Photographs of the accident scene, vehicle damage, and injuries
• Expert opinions (if applicable) challenging the insurer’s position
• Communication records showing compliance with policy requirements

Step 4: Write Your Appeal Letter

Your appeal letter should be professional, organized, and evidence-based. Include:

1. Identify the claim: Reference your claim number, policy number, and the date of the denial letter
2. State your disagreement: Clearly state that you are appealing the denial and why
3. Address each denial reason: For each reason the insurer cited, present evidence and arguments that counter the insurer’s position
4. Cite policy language: Reference the specific policy provisions that support coverage
5. Cite Georgia law: Reference relevant statutes, including O.C.G.A. § 33-4-6 (bad faith), O.C.G.A. § 33-6-34 (unfair claims practices), and any applicable case law
6. Attach supporting evidence: Include all documentation supporting your appeal
7. State a deadline: Request a response within a specific timeframe (30 days is reasonable)

Send the appeal letter via certified mail with return receipt, and keep a copy for your records.

Step 5: Follow Up

If the insurer does not respond to your appeal within a reasonable time, follow up in writing. Document every communication. Unreasonable delays in responding to appeals can be evidence of bad faith.

What to Do If Your Appeal Is Denied

If the insurer upholds the denial after your appeal, you have several options:

File a Complaint with the Georgia DOI

The Georgia Department of Insurance investigates complaints about unfair insurance practices. A DOI complaint creates a regulatory record and may pressure the insurer to reconsider. See our guide on how to file a Georgia DOI complaint.

Send a Bad Faith Demand Letter

Under O.C.G.A. § 33-4-6, you can send a formal demand for payment. If the insurer fails to pay within 60 days and the refusal is later found to be in bad faith, the insurer faces a penalty of up to 50% of the claim amount plus attorney’s fees. Learn more about bad faith insurance in Georgia.

Pursue Arbitration or Mediation

Some policies include arbitration or mediation clauses. These alternative dispute resolution processes can be faster and less expensive than litigation, though they have limitations.

File a Lawsuit

If all else fails, you can file a lawsuit in Georgia court. Your claims may include breach of contract (the insurer failed to honor the policy), bad faith (under O.C.G.A. § 33-4-6), unfair claims practices (under O.C.G.A. § 33-6-34), and unfair business practices (under O.C.G.A. § 10-1-393).

Red Flags: When a Denial May Be in Bad Faith

Not every denial is bad faith — insurers do have the right to deny claims they believe are not covered. But the following signs suggest the denial may be improper:

• The denial letter is vague and does not clearly explain the reason
• The insurer denied the claim without conducting a thorough investigation
• The denial contradicts the policy language
• The insurer ignored evidence supporting your claim
• The insurer relied on a biased “independent” medical examination
• The denial is based on a technicality rather than the merits of the claim
• Other claimants in similar situations have had their claims paid

Frequently Asked Questions

Why was my insurance claim denied?

Common reasons for insurance claim denials include: policy exclusions, disputed liability, lapses in coverage, failure to report the accident promptly, pre-existing conditions, disputed medical necessity, and alleged fraud or misrepresentation. The denial letter should specify the reason. If it does not, you have the right to request a detailed explanation.

How long do I have to appeal an insurance denial in Georgia?

There is no single deadline for all insurance appeals in Georgia. Your policy may specify a time limit for internal appeals. For external remedies, Georgia’s statute of limitations for breach of contract (insurance policy) is six years (O.C.G.A. § 9-3-24), and for bad faith claims, the limitations period depends on the type of claim. However, you should appeal as quickly as possible — delays can weaken your position.

Can I sue my insurance company for denying my claim in Georgia?

Yes. If your insurer wrongfully denies a valid claim, you can file a lawsuit for breach of contract and, if the denial was in bad faith, you can seek additional penalties under O.C.G.A. § 33-4-6 (up to 50% of the claim value plus attorney’s fees). You should also consider filing a complaint with the Georgia Department of Insurance.

Should I hire a lawyer to appeal an insurance denial?

While you can appeal on your own, hiring an attorney is strongly recommended for significant claims. An attorney can analyze the denial reason, identify legal errors in the insurer’s position, gather supporting evidence, draft a compelling appeal, and pursue legal action if the appeal fails. Most personal injury attorneys work on contingency, meaning you pay nothing unless they recover money for you.

What happens if my appeal is denied?

If your internal appeal is denied, you still have options. You can file a complaint with the Georgia Department of Insurance, pursue mediation or arbitration (if available under your policy), send a bad faith demand letter under O.C.G.A. § 33-4-6, or file a lawsuit in Georgia court. A denied appeal does not mean the end of the road.

Need Help Appealing a Denied Claim?

A denied insurance claim does not have to be the end of the story. The attorneys at Wetherington Law Firm have extensive experience challenging insurance denials and know how to hold insurers accountable when they refuse to honor their obligations.

Call us today at (404) 888-4444 for a free consultation. We will review your denial, assess your options, and fight for the compensation you deserve.

Hablamos Español: (404) 793-1667