When refusing claims, you should?

Asked by: Webster Tillman  |  Last update: June 13, 2026
Score: 4.8/5 (24 votes)

When refusing claims, you should be clear, empathetic, and objective, explaining the specific reasons for denial using policy details while avoiding blame, and providing clear next steps for the claimant, such as appeal procedures, to maintain professionalism and guide them on how to potentially resolve the issue.

When refusing claims, one should?

When refusing claims, it is important to handle the situation professionally and respectfully. Here are the recommended steps to follow: Use the direct approach: Clearly state the reason for refusing the claim without beating around the bush. This helps to avoid confusion and ensures transparency.

What to say when insurance denies a claim?

When insurance denies a claim, you should request the specific reason for denial, then file a formal internal appeal within the deadline, providing a clear, detailed letter explaining why they should reconsider, referencing policy language, and attaching strong supporting evidence like doctor's notes, records, or repair estimates. If the internal appeal fails, escalate to an external review, or contact your state's insurance regulator or a consumer assistance program for help. 

When denying a claim, what approach should you not use?

When denying a claim, avoid using preachy "you" statements and accusations implying dishonesty. Instead, focus on clear, objective communication that provides reasons before stating the refusal. This approach helps maintain professionalism and good customer relations.

How do you professionally deny a claim?

Best Practices To Follow When You Decline A Customer's Request

  1. 💡 Listen To & Understand The Request.
  2. 💡 Be Empathetic Towards The Customer.
  3. 💡 Start With A Sincere Apology.
  4. 💡 Keep Your Reply Short & Simple.
  5. 💡 Explain The Rejection With Clarity.
  6. 💡 Use A Positive Tone to Decline Requests.
  7. 💡 Carefully Personalize Your Response.

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28 related questions found

What are the two main reasons for denying a claim?

Common denial reasons: Missing documents, missed deadlines, incomplete claim forms, policy exclusions, lack of sufficient evidence, coverage lapses, or failure to follow claim procedures often lead to denial.

How to politely refuse a request?

50 different ways to say no politely

  1. “Sadly, I have something else going on.”
  2. “I wish I were able to.”
  3. “Sorry, I'm afraid I can't.”
  4. “I'm flattered, but I'll have to sit this one out.”
  5. “I'm sorry, I'm unable to fit this in.”
  6. “No, thank you, but it sounds lovely.”
  7. “I'll have to take a rain check.”

What are the three most common mistakes on a claim that will cause denials?

Here, we discuss the first five most common medical coding and billing mistakes that cause claim denials so you can avoid them in your business:

  • Claim is not specific enough. ...
  • Claim is missing information. ...
  • Claim not filed on time (aka: Timely Filing)

Does insurance go up if a claim is denied?

Since insurers base premiums on how likely policyholders are to file a claim, a claim that's denied can cause your rates to go up — though not as much as if the claim was approved. Even discussing a claim with an agent, without actually filing it, can impact your premiums.

What should you not say in a claim?

Don't Say Things That Will Reduce the Value of Your Claim

  • I'm feeling much better.
  • This really isn't so bad.
  • I've been through worse.
  • I don't know what my doctor is so concerned about.
  • This isn't such a big deal.

What is the 80% rule in insurance?

The "80% insurance rule" in homeowners' insurance requires you to insure your home for at least 80% of its total replacement cost to avoid coinsurance penalties and receive full payout for partial losses, ensuring you can rebuild without major out-of-pocket costs, with replacement cost considering materials, labor, and local costs, excluding land value. Failing to meet this threshold means the insurer pays only a proportional amount of your claim, leaving you responsible for the rest. 

What not to say to an insurance claim adjuster?

When talking to an insurance adjuster, avoid admitting fault, apologizing, speculating on injuries or damages, agreeing to recorded statements, accepting quick settlement offers, and posting on social media, as these statements can be used to weaken your claim; instead, stick to basic facts, be brief, and consider consulting a lawyer before giving detailed information. 

How to reject an insurance claim?

Communicating with the Claims Adjuster

Your legal representative can help you write a letter that states your intentions. Within the letter, you can indicate that you reject the offer and highlight why you deserve a higher settlement amount. You should also counter their reasons for offering the lowball initial offer.

What is the most common claim denial?

Claim not filed on time (aka: Timely Filing)

If a proper claim is submitted, but it's not within the timing window, it may result in a denial. It is recommended that you check with your Payers regarding their filing deadlines.

Can I sue insurance for denying a claim?

When the insurance company fails to honor your policy or refuses to compensate you for your losses, you have the right to file a lawsuit. Insurance companies are typically profit-driven, but while denying your claim may be in your provider's best interest, it's not in yours. You have damages that require compensation.

Which of the following should you do when making your case for refusal?

State your refusal using dismissive language. Apologize profusely for being unable to accommodate the reader's request.Be sure to use negative. Which of the following should you do when making your case for refusal? Explain your company ' s relevant policy.

What insurance denies most claims?

There's no single "worst" company for denials, as it varies by insurance type (health, home, auto) and year, but UnitedHealthcare (UHC) and AvMed often top health insurance lists with rates around 33%, while Farmers and USAA affiliates showed high home denial rates in California (around 50%) in 2023. Progressive is known in legal circles for aggressively denying auto claims, and specific Florida homeowners' insurers like People's Trust have very high denial rates for storm claims. 

How much will my insurance go up after one claim?

After a claim, insurance rates typically increase, often by 20% to 50% or more for at-fault auto accidents, depending on the severity, your driving history, and the insurer, with serious incidents or multiple claims leading to bigger hikes, while non-fault or comprehensive claims (like hail, theft) might only cause slight or no increases, as factors like age, location, and the specific incident type all influence the final price. 

When a claim is denied, it is best to?

If your resubmitted claim is denied and you believe the denial was improper, you may appeal the decision according to the carrier's guidelines. Make sure you know exactly what information you need to submit with your appeal. Keep in mind that appeal procedures may vary by insurance company and state law.

What is the 80 20 rule in insurance?

The 80/20 Rule, part of the Affordable Care Act (ACA), requires health insurers to spend at least 80% of premium dollars on medical care and quality improvement, with the remaining 20% for administrative costs (salaries, marketing, profit). For large group plans, the requirement is 85%. If insurers don't meet these Medical Loss Ratio (MLR) standards, they must issue rebates to consumers.
 

What are 5 reasons a claim may be denied?

Five common reasons for claim denial include incorrect or missing patient/provider info, lack of medical necessity, missing prior authorization, coding errors, and filing the claim too late, with other issues involving non-covered services or policy exclusions being frequent culprits, all leading to payment rejection by insurers. 

What are the three things that make a strong claim?

To be strong and effective, a claim should be debatable, focused, and specific. In other words, it ought to be something that can be argued with reasons and evidence, and it ought to be narrow enough to properly support or prove in the space and format available.

What is the best decline message?

Thank you for your interest in the [Position] role at [Company]. We appreciate the time and effort you invested in applying for this position. After careful consideration, we have decided not to move forward with your application at this time.

What should you avoid saying when rejecting?

What not to do:

  • Give them false hope by saying, “Maybe later.”
  • Ghost them and leave them hanging.
  • Use cliches like “It's not you, it's me.”

How to decline without offending?

Here are a few variations to practice:

  1. Thanks for thinking of me. I can't right now/I can't make it/I can't attend.
  2. I'm at capacity right now, so I will decline. Thanks for understanding.
  3. No, not at this time.