Why insurance claims are denied (and when you can challenge the decision)

Real cases: when an innocent sentence changes the entire claim

In many insurance claims we review, the real problem is not the damage or the policy, but a sentence said in good faith, at the wrong moment.

These are two real (anonymous) cases that show how a poorly handled conversation can completely derail a claim.

Case 1 — A wall collapsed after Filomena… and a pool that had nothing to do with it

After the Filomena weather event, a homeowner suffered the collapse of a retaining wall and a massive flow of water into the boundary with the lower neighboring property.

During the inspection, the adjuster noticed an empty removable pool at a higher level and asked whether it had been filled during the previous summer. The insured, acting honestly, answered yes.

That single answer was enough for the adjuster to:

• link the collapse to an alleged prior emptying of the pool
• ignore the extraordinary meteorological context
• overlook that other walls in the same residential area had also collapsed

The result was a denial of coverage based on an unproven assumption.

The claim could only be recovered by:

• proving that the pool had been emptied before the weather event
• documenting similar damage in surrounding properties
• and technically dismantling the assumed causal link

Legal action was required, and an out-of-court settlement was eventually reached.

There was no bad faith by the insured.
Just one sentence too many.

Case 2 — “The last time nobody paid me anything”

In another case, a client suffered water damage coming from the apartment above. Coverage was accepted, and the adjuster assessed the damaged contents at around €5,000.

During the visit, upon hearing the amount, the insured casually commented:

“Last time my furniture got wet, nobody paid me anything.”

That remark was interpreted as:

• possible pre-existing damage
• an undeclared recurring issue
• or lack of correspondence between damage and the current loss

The consequence was immediate: the proposed compensation was withdrawn.

The claim had to be fully restructured. Part of the amount was eventually recovered, but not the full originally assessed sum.

Again, no bad faith.
Just an unnecessary comparison.

👉 If you have already spoken with your insurer and fear the claim has been misdirected, it may still be reviewed before it is definitively closed.
Request a technical review of your claim

Why this happens (and why it’s not personal)

Insurers do not listen the way a private individual would.

They analyze conversations looking for:

• contradictions
• potential exclusions
• signs of pre-existing damage
• arguments to limit coverage

Everything is recorded.
And it is not always interpreted in the insured’s favor.

That is why explaining background issues, comparisons, hypotheses or temporary fixes often works against you.

👉 Basic rule: talk only about the current damage and what you can see, not interpretations or past experiences.

When silence and insistence make things worse

Another common pattern is the combination of:

• prolonged silence from the insurer
• repeated calls from the insured
• increasingly detailed explanations

In many cases, silence is not neutral. It leads to:

• exhaustion
• contradictions
• acceptance of reduced settlements

We explain how to act in these situations here:
My insurer is not responding: what to do when the claim is blocked

Underinsurance, low valuations and accumulated errors

These communication mistakes are often compounded by technical issues such as:

• incorrectly calculated underinsurance
• automatic application of proportional rules
• incomplete loss assessments
• omitted damage items

The result is a claim weakened on multiple fronts.

We analyze these mechanisms in detail in:

• Underinsurance and how it affects claims
• Low loss assessments: why they happen

👉 When the compensation does not allow proper repair or replacement, a technical review of the claim is usually the first step to determine whether there is real room for correction.
Review my claim

Conclusion

Many claims are not lost due to lack of coverage, but because of perfectly understandable human errors.

Talking too much, comparing with previous incidents, or trying to “help” by explaining hypotheses can turn a valid claim into a denied or reduced one.

When an insurer says no, the key is not to argue blindly, but to understand what went wrong in the approach and correct it with technical criteria.

These situations are part of the cases we analyze daily at MataSeguros, helping policyholders recover claims that seemed lost and defend compensation that rightfully belongs to them.