Death, Taxes, and Insurance Denials & Diminishments

A policyholder chatbot trained by community claims experiences
Insurance denial solution

Death, Taxes, and Insurance Denials & Diminishments

100% of Americans will experience a denial or diminishment in their lifetime.

Whether it’s denial of coverage for a medical procedure that your doctor feels is necessary or diminishment of a property value claim because the “cash value” of your possessions has depreciated away to nothing, every American is almost certain to experience a denial or diminishment and have no recourse outside of filing a lawsuit.

Some denials are warranted; however, too many of us are left feeling too many of these denials are unfair or hint at bad faith. My experience  certainly puts me in that position. We’ve all heard the stories, but that’s the problem, they’re anecdotes.

Power Imbalance

Insurance companies are in the driver’s seat when settling a claim. Insurance carriers have more negotiating strength and financial resources than the policyholder. Recognizing this, most courts find an obligation of good faith and fair dealing in every insurance policy.” – FindLaw

Insurance is in the only industry where the customer relationship is adversarial: customers are a clear and present danger to profits. This is much more than a mere shift in power dynamic, so the obligation of fair dealing is insufficient to protect consumers’ interests.

The UNFAIR Insurance Act

The path to getting legislation passed is long and the odds, when facing an industry with deep pockets and powerful political influence, are low. We should walk the path, but we should also look for some immediate relief.

Policyholder ClaimBot

I wrote ClaimTally in a hurry to solve an immediate need. My recent experience makes me realize there’s actually a better use case for AI to help consumers deal with the insurance industry. If we collect consumers’ stories on claims, denials, and settlements, we can train an AI model to help consumers navigate, fight, and win the claims process.

For example, if you read my story in the prior post, did you spot my mistake? I relied on the environmental test and a set-aside of items I thought would show mold spores to support my claim, along with a “problem solving” attitude from the insurance carrier. (I’ll admit, naïveté bordering on stupidity on my part!) What I should have done is tested those items in advance and provided those results, rather than trusting the insurance company to test what I’d set aside for them or suggested in subsequent communications.

Once they found the negative result they needed for plausible deniability, they were done. I’ll hire a process server, a testing service, invite a few witnesses that will make sworn statements, and film the truck’s arrival and the testing to avoid later accusations when the lab results are returned. What an expensive hassle that I suspect many consumers would choose not to undertake, particularly if you were a single parent with a full-time job.

Had I been able to consult a chatbot trained on a large dataset of past claims, successes, and denials, there’s a good chance the AI would have given me a list of steps most likely to speed up a successful claim avoiding this pitfall, avoiding the industry’s “just plausible enough not to be bad faith” tricks. I had the advice of two lawyers on this process, and they BOTH missed this as well as me, and they’re both competent and experienced. With training data, an AI chatbot could have avoided this misstep at a price a single parent can afford.

Submit Your Story

Success or failure, your story helps improve the system for others. We’ll use AI to summarize and look for patterns of insurance company behaviors that may warrant a new provision in The UNFAIR Insurance Act, and we’ll tune the bot with everyone’s stories to help you navigate your own claims process in the future. Perhaps it’ll show how others gained approval for that expensive medically-necessary procedure that was auto-denied, or help you avoid the roof leak the insurance company turns into two separate claims (requiring two separate deductibles, thus unfairly diminishing your claim).

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