Tag Archives: NC Statutes on unfair claim settlement practices

Insurance company intimidation tactics, Fraud allegations bullying, Manipulate situation by choosing what information is relevant, NC Statutes on unfair claim settlement practices

Insurance company intimidation tactics, Fraud allegations bullying, Manipulate situation by choosing what information is relevant, NC Statutes on unfair claim settlement practices

“For members who have found themselves in disputes with Thrivent, the retroactive change rankles. “You’re wondering how Lutheran organizations can treat their own customers that way,” says Mr. Tiedemann, an 83-year-old retiree who navigated the dispute-resolution process for more than two years before giving up.”...WSJ May 30, 2006

“The insurance companies understand that if they deny and deny claims, then many of the claimants will never pursue their claim,”…ABC News Good Morning America April 25, 2008

“pre-dispute mandatory arbitration provisions are inappropriate in insurance policies and incompatible with the legal duties insurers owe policyholders when handling their claims.”…NAIC, National Association of Insurance Commissioners, August 15, 2016


How Do Insurance Companies Use Intimidation Tactics?

“One of the ways an insurance company may try to manipulate the situation is by choosing what information is relevant. If they discover some key information that wasn’t previously communicated to them, they might choose to punish you for not telling them, instead of simply assuming you had made a mistake and asking you to supply the missing information.”

“Unsubstantiated Fraud Allegations: Many insurance providers will allege that their policyholder is engaged in fraud by inflating the value of items in their claim, fabricating events resulting in loss or claiming loss of items that do not exist or were not lost or damaged. Sometimes these allegations will be loosely based on mistakes on a proof of loss form or be completely without any factual support. The objective is to intimidate a policyholder into accepting a lowball offer because of fears that the insured will face potential civil or criminal liability as well as having his or her claim completely denied.”


From AcomHealth.

“It is a very common device for claims adjusters to allege “fraud” as a means to drive a minimal financial settlement with a provider. The claim by some insurance company employee that “overutilization” has taken place and that somehow, based on self-serving and unreal “guidelines” they are exploring legal action against the provider is, indeed, sobering and probably as intimidating as it is intended to be. As absurd and unethical as this behavior is, it is frequent and it is effective in driving low-dollar settlements by providers even for the most legitimate of claims.”

“While the exact language in the law regarding fraud may vary from state to state, the common elements necessary to prove fraud might be summarized as follows:

Fraud must be proved by showing that the defendant’s actions involved five separate elements:

  1. A false statement of a material fact,
  2. Knowledge on the part of the defendant that the statement is untrue,
  3. Intent on the part of the defendant to deceive the alleged victim,
  4. Justifiable reliance by the alleged victim on the statement, and
  5. Injury to the alleged victim as a result. Source:  Farlex Internet Free Dictionary”

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NC Statutes.

“§ 58-24-165. Unfair methods of competition and unfair and deceptive acts and practices. Every society authorized to do business in this State shall be subject to the provisions of Article 63 of this Chapter relating to unfair methods of competition and unfair or deceptive acts or practices”


“(11) Unfair Claim Settlement Practices. – Committing or performing with such frequency as to indicate a general business practice of any of the following: Provided, however, that no violation of this subsection shall of itself create any cause of action in favor of any person other than the Commissioner:
a. Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue;
 b. Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies;
c. Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies;
d. Refusing to pay claims without conducting a reasonable investigation based upon all available information;
e. Failing to affirm or deny coverage of claims within a reasonable time after proof-of-loss statements have been completed;
 f. Not attempting in good faith to effectuate prompt, fair and equitable settlements of claims in which liability has become reasonably clear;
g. Compelling [the] insured to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insured;
h. Attempting to settle a claim for less than the amount to which a reasonable man would have believed he was entitled;
 i. Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of, the insured;
 j. Making claims payments to insureds or beneficiaries not accompanied by [a] statement setting forth the coverage under which the payments are being made;
k. Making known to insureds or claimants a policy of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration;
 l. Delaying the investigation or payment of claims by requiring an insured claimant, or the physician, of [or] either, to submit a preliminary claim report and then requiring the subsequent submission of formal proof-of-loss forms, both of which submissions contain substantially the same information;
 m. Failing to promptly settle claims where liability has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage; and

n. Failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement.”

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