Insurance companies can refuse a policyholder's claim with either a "disclaimer of liability" or a "denial of coverage." The similarity between the two terms might lead you to think they are interchangeable, but the meanings are distinct in terms of the insurance agreement. Examining the traditional distinction between a denial and a disclaimer can demystify the factors that lead insurance companies to refuse to provide a policyholder coverage.
The Technical Difference
The distinction between an insurance company's denial of coverage and disclaimer of coverage ultimately lies in whether or not the company finds that the claim in question ever fell within the scope of the policy's coverage. A denial applies to a claim that is declined because it falls outside the scope of coverage, while a disclaimer pertains to claims that initially fall within the scope of coverage but are invalidated by an intervening factor.
What Denial Means
A denial of coverage occurs when a claim against a policyholder does not fall within the scope of the coverage described in the insurance agreement, or when the policyholder fails to satisfy a condition precedent to coverage. A condition precedent is some event or action that must happen before the insurance company's duty to provide coverage arises.
Under these circumstances, a company's denial asserts that its insuring responsibilities under a policy do not arise at all. In this way, the term "denial of coverage" could apply equally to a claim by a person who is not yet a policyholder -- such as when an insurance applicant is denied a coverage policy -- or to a current policyholder's claim that stems from an intentional injury instead of an accident.
What Disclaimer Means
A disclaimer of coverage, on the other hand, occurs when a claim initially falls within the scope of coverage and the policyholder has satisfied any conditions precedent to coverage. What provokes the disclaimer is a breach of contract by the policyholder or an exclusion within the insurance policy itself that bars coverage for the claim in question.
When an insurance company disclaims coverage in this context, it essentially admits that the terms of its insuring responsibilities under the policy have arisen, but it further asserts that those responsibilities have been invalidated by an intervening factor, such as a breach by the policyholder or an applicable exclusion to the terms of the policy. In this way, a "disclaimer" applies to a claim for which a policyholder refuses to provide necessary information and equally to a claim for the expense of cleaning up nuclear waste, where the policy in question specifically excludes claims stemming from nuclear reactions.
Why the Difference Matters
Despite the distinctions outlined above, it is exceedingly easy -- even for claims examiners and insurance attorneys -- to mix up the terms "denial" and "disclaimer," to the point where the two have become all but functional synonyms. Nevertheless, identifying the precise nuances of legal terms like "denial of coverage" and "disclaimer of coverage" helps policyholders to understand when and why their insurance companies might decline a claim -- and to know when to fight against it.
Nat Noda published his first law article in 2008. His work has appeared in law journals such as the "Creighton Law Review" and "Journal of the Copyright Society." Noda holds a Juris Doctor from the William S. Richardson School of Law, as well as a Bachelor of Arts in philosophy from Santa Clara University.