Filing an insurance claim can be frustrating. Maybe you’re waiting for an update that hasn’t come yet, or you expected a check and instead got a list of questions. From the outside, it can feel like nothing is happening. But behind the scenes, a lot of moving parts — file reviews, coverage checks, vendor assignments and internal approvals — can slow the process.
Insurance is one of the most regulated industries. Adjusters can’t just make up the rules as they go. Claims are governed by state laws and regulations, many of which are based on national guidelines like the Unfair Claims Settlement Practices Act (UCSPA). These rules exist to ensure fair treatment.
As a former adjuster, I worked under these rules. As an expert witness hired by attorneys in bad-faith lawsuits, I use them to determine if carriers breached standard claims handling procedures. Here are some of the most important — and how they protect you as a consumer.
Rule #1: Adjusters must explain the policy to you
Insurance policies are complex, but adjusters are required to interpret and explain them accurately. While policyholders are expected to read and understand their coverage, adjusters are trained to walk you through what is — and isn’t — covered under your policy. This includes clarifying how endorsements, exclusions and limits may apply to your specific claim.
Why this rule matters: Insurance contracts can be difficult to interpret, even for seasoned professionals. Adjusters are expected to help bridge that gap — not only for transparency’s sake, but also to avoid confusion that can delay your claim or lead to a denial you weren’t expecting. They should also inform you if any additional damage or conditions may be covered by your policy.
This rule applies to first-party claims — those involving your own policy. In most states, third-party claimants (such as someone filing against your liability coverage) are not entitled to policy details unless a lawsuit has been filed.
From the field: Even the most seasoned professionals can make a mistake, and not every mistake an adjuster makes in the interpretation of the policy amounts to bad faith — intent and frequency matter. As an expert witness, I’ve seen dozens of claim files where the adjuster failed to explain coverage clearly. When that happens, misunderstandings and distrust grow — and so do the chances of a dispute.
For example, in a homeowners insurance policy, there are additional coverage options — extra money — available for things like debris removal and increased cost of construction, just to name a few. When this coverage is paid is currently a hot topic in the insurance industry. However, if the policyholder is not informed when and how to obtain these additional funds, they are missing the full benefit of their policy.
Rule #2: Adjusters must respond to your claim within a reasonable timeframe
When you file a claim, the clock starts ticking. In many states, insurers have 10 and 15 days to acknowledge your claim and begin investigating. That includes responding to emails, answering questions and requesting documents in a timely manner.
Why this rule matters: When your home is damaged or your car is in a shop, two weeks can feel like forever. State regulations are in place to keep the process moving and make sure claimants aren’t left waiting without answers. These timelines are not uniform — they vary by state, and in some cases, it’s not the department of insurance, but a court decision that ends up setting the standard.
Even when there’s no specific day-count written into law, many states fall back on a broader requirement: that the insurer respond and act within a “reasonable” time. That’s a legal term — one rooted in what an ordinary person would consider acceptable under the circumstances. What’s reasonable after a fender bender isn’t the same as what’s reasonable after a total loss from a fire. But in every case, it reflects what the industry and the courts expect from carriers and adjusters alike.
From the field: Most delays aren’t driven by bad intentions. Often, it’s as simple as an adjuster failing to set a diary — a reminder — and the claim falls off their radar. I reviewed a file which had not been touched by the adjuster in six weeks. The adjuster had the estimate of damages. He needed to review it, apply coverage and, barring any exclusions, issue payment. In the diary system, I saw that the adjuster had deleted the note to follow up on the estimate. The adjuster simply forgot to add a new diary to review the estimate, coverage and issue payment.
Rule #3: Insurers must tell you, in writing, why they are denying the claim
If your claim is denied, the insurance company has to explain why — in writing — and they must reference the specific policy language that supports the denial. This is a specific legal requirement in nearly every state. Some even mandate that denial letters include specific language about how to contest the decision or contact the state department of insurance.
Why this rule matters: Insurance policies are full of dense, technical language. If a claim is denied, a vague explanation like “it’s not covered” doesn’t cut it. The insurer has to point to the part of the policy that supports their decision. That transparency helps you decide what to do next — whether that’s accepting the denial or fighting back.
From the field: I was working as an expert witness on a lawsuit that had been denied for “wear and tear.” That exclusion is common — but so is the exception that says if the resulting damage is from a sudden and accidental event, that damage is covered. I reviewed the denial letter and immediately flagged that the exception hadn’t been considered. Once the attorney saw that, the case took a very different direction. That written explanation — and what it left out — became the key to challenging the decision.
What to do if your claim isn’t progressing as expected
Not every disagreement with your adjuster means something shady is happening. Sometimes delays are due to volume, a misunderstanding or simple oversight, which can be corrected with clarification.
For example, I contacted an insured for a cannabis theft claim. For months, I had been asking for documentation. When it finally arrived, the receipts were vague, generic, sequential and written with the same pen. There were no last names, no telephone numbers or email addresses. This was indicative of fraud. I informed the insured I was going to report him to the fraud department. He didn’t want to give me the information because he was afraid of betraying the trust he had with his cannabis farmers. Once I understood why the insured wasn’t cooperating, I could process payment. That delay was on me — but it wasn’t misconduct. It was a misunderstanding that could have been avoided if I had just slowed down and listened.
Unfortunately, not every claim issue can be resolved with better communication. If the process isn’t matching the timeline you were led to expect, or if you’re struggling to get clear answers, there are steps you can take:
- Document everything: Save emails, take notes during calls, and get things in writing whenever possible.
- Ask for a copy of the claim file: Some states let you request your claim file, which includes notes, photos and correspondence. This can help you better understand what’s happening with the claim and take action if you think it’s being mishandled.
- Escalate to a supervisor: If you’re hitting a wall, ask (politely but firmly) to speak with someone higher up.
- Contact your state’s insurance department: Every state has an agency that investigates complaints. You can often file complaints online.
- Talk to a professional: A public adjuster or attorney may be able to help if your claim is large or especially complicated.
The bottom line
These regulations may feel procedural or bureaucratic at times, but they exist to protect you. Carriers are required to follow specific rules, and while mistakes happen, those rules set a baseline for fairness and accountability.
Not every violation is an act of bad faith. Adjusters are human and errors occur. But when violations are repeated, intentional or done with disregard for the insured, that’s when legal consequences may follow. Understanding your rights and the standards adjusters are supposed to meet helps you advocate for yourself and spot the difference between delay and true mishandling.
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