If a motorist and/or their passengers sustain injuries as a result of a motor vehicle collision, a claim is most often filed with the at-fault party’s insurance carrier. Similarly, this also pertains to a person or, persons, who suffer a personal injury as a result of a premises liability occurrence. The claim is then assigned to an adjuster who specifically keeps track of the injured party, or parties, treatment, and medical expenses incurred. At this point, an insurance adjuster places a reserve on what the case could value may be, depending on the initial type of injuries sustained.
Once treatment is complete, upon receipt of the complete medical records and itemized bills referencing the treatment received by the injured party, an adjuster then evaluates all documentation to determine the value and settle the claim. First, it is important to keep in mind that every adjuster is different with regard to the way a personal injury claim is evaluated for settlement.
Insurance adjusters will utilize various aspects of the claimant with regard to what determines the settlement value in a personal injury claim, such as lapses in treatment, inconsistencies in treatment, pre-existing injuries, impact v. treatment, treatment provider, the total amount of medical expenses incurred, prior claims for injuries, and prior treatment for the claimed injury, or injuries sustained.
One of the reasons that it is imperative to seek medical care following a motor vehicle collision, or premises liability occurrence, is due to the fact that any delay in treatment immediately following the collision, or premises liability injury only complicates a claim. The reason being is that insurance adjusters specifically look for the type of injuries claimed to be sustained as a direct result of the collision, or premises liability occurrence. Any delay in seeking that treatment leaves room for doubt on the injuries claimed.
In addition to seeking medical treatment as soon as possible following an injury, it is imperative that when you are seeking initial treatment it is with a medical professional, whether it is through a local emergency room, urgent care center, or primary care physician. There is a clear distinction between a licensed practitioner and a medical physician, and the type of provider seen is another factor that insurance adjusters take into consideration when evaluating a personal injury claim for settlement. Furthermore, it is important to keep in mind that insurance adjusters take into account the type of provider that administers the initial medical evaluation, treatment, course of care, prescriptions, and/or diagnosis of an injured party.
Additionally, insurance adjusters take into consideration the recommended course of treatment, which includes lapses or inconsistencies in the suggested course of care. Here is an example, when a person presents to the emergency room directly after a collision, the injured party is more than likely discharged with, or without, prescription medications and is generally advised to follow-up with their primary care physician. As instructed, the injured party presents to their primary care provider and the injured party is then referred to chiropractic care or physical therapy. Any lapse or inconsistency in treatment with that recommended course of care can raise some immediate red flags, placing further doubt on whether or not the claimant is as injured as they allege. Likewise, insurance adjusters also take into consideration excessive treatment based on the injury, or injuries claimed, and again, the type of provider recommending and/or administering the treatment. An included factor that is taken into consideration for the settlement of a claim is duplicate or disproportionate charges for the medical treatment rendered. Another equally important factor insurance adjusters take the type of medical treatment rendered is to rule out any drug-seeking behavior.
Other factors that can directly influence the insurance adjuster’s evaluation of a personal injury claim are pre-existing conditions, prior injuries, and/or prior accidents. Starting with pre-existing conditions, these can consist of chronic pain such as the neck, back, shoulder, osteoarthritis, arthritis, and degenerative disc disease. Prior injuries are also another important factor taken into consideration; these can consist of herniated or bulging discs, surgeries, injections, and/or pain management. The reason pre-existing conditions, and prior injuries are taken into consideration is because these areas can be more easily affected. Prior accidents or collisions can also influence the insurance adjuster’s evaluation in settlement for a claim, for obvious reasons such as patterns in numerous personal injury claims made, as these patterns can be reflective of insurance fraud.
The impact versus injury aspect really ties all these factors together in the evaluation of settlement for a personal injury claim. As you may be aware, injuries can be sustained for a high impact or low impact collision, however, not all injuries claimed are the same. As previously stated, every insurance adjuster is different, and there is no real way to determine how the information of every different aspect is used to determine the evaluation in a settlement of a claim. Furthermore, in addition to the type of injuries sustained, the type of medical treatment rendered to the claimant will be thoroughly taken into account such as radiologic imaging studies, occupational therapy, and/or physiotherapy, or if the claimant required treatment with any specialists like an orthopedic or neurosurgeon. Moreover, depending on the severity of the collision, the length of overall treatment is considered, if a claimant sustained injuries that required them to be evaluated and/or treated by a psychologist or psychiatrist.
Finally, additional factors taken into consideration by an insurance adjuster when evaluating the settlement of a personal injury claim is whether or not future medical treatment will be required, pain and suffering, and wage loss. More often than not, a soft tissue injury such as pain in the neck, back, shoulders, head, upper extremities, and/or lower extremities, do not carry the same “weight” or value as an injury that results in fractures, traumatic brain injuries, and/or surgical intervention. Even though an injury that results in broken bones may or may not require additional treatment such as therapy, the type of injuries that are severe enough to warrant major or multiple surgeries certainly does, increasing the cost of the medical bills as a result. This increase in the medical expenses incurred is compared to the severity of the impact in an injury, the affected area, and whether or not the claimant was recommended and followed with the appropriate course of care, and this information is what adjusters consider when settling a personal injury claim.
