What can I do if my insurance company denies my claim in Texas?

Your options depend on the type of insurance that is at issue. Generally, here are some basic steps to follow: 

1. Get the details of the denial. Read the denial letter for the specific reason and the policy provisions cited. Ask the insurance company in writing for your claim file. Under the Texas Prompt Payment of Claims Act, insurance companies generally must accept or reject a claim in writing, with reasons, within about 15 business days after receiving everything they requested, though this can be extended in some situations.

2. File any required internal appeal. Most insurance companies have an internal appeal process. Submit any new evidenand keep copies of everything you send. 

3. Your remedies depend on the applicable insurance.

• Health insurance: For state-regulated plans, if the denial is based on medical necessity, you can request an Independent Review Organization (IRO) review through TDI. The IRO’s decision binds the insurer. If your plan is self-funded by your employer (ERISA), different federal rules apply.
• Homeowners or auto: Many policies include an appraisal clause for disputes over the amount of loss. 
• Disability or life insurance through an employer: These are usually governed by ERISA, which has strict appeal deadlines and limits what you can recover in court. Missing the internal appeal can be fatal to your claim.

4. Possible legal deadlines that apply. Texas law provides several claims against insurance companies that wrongfully deny or delay claims:

• Prompt-payment penalties (Insurance Code Chapter 542) include interest on the unpaid claim + attorney’s fees. 
• Unfair claim settlement practices, such as denying without a reasonable basis (Chapter 541)
• Breach of the common law duty of good faith and fair dealing.
• Breach of contract.

For property claims involving weather damage, Chapter 542A generally requires written pre-suit notice at least 61 days before filing suit. Other claims may require notice as well, such as 60 days under the Deceptive Trade Practices Act.

5. Watch any contractual deadlines. Policies can set suit-filing deadlines, which Texas law won’t let be shorter than two years. ERISA appeals and some notice requirements are much shorter. Check your policy for more details.