What Adjusters Look for in Evaluating Claims

In evaluating how much to offer to pay you on your insurance claim for bodily injury, the insurance adjuster will consider the following factors.

Causal relationship between the accident, injury, and medical records

Adjusters examine closely at the medical records sent to them by a personal injury attorney in conjunction with a client’s claim for damages. They look for:

  • Medical opinion(s) supporting the length of disability claimed;
  • Medical opinion(s) supporting a claim of permanent injury or scarring;
  • Notation of prior claims or injuries;
  • Mention of pre-existing conditions or injuries to the same body part;
  • Any mention of intoxication, alcohol or drugs; and
  • Reference to the history that deviates from the “official” account of the accident that has been represented to the adjuster.

For example, in one case, the claimant alleged injury to her back when she fell off of a physical therapy table. She asserted a product liability claim, contending that the table was defective. The claimant’s injury attorney sent her medical records to the insurer. These records did not mention any fall off of a physical therapy table. They did, however, relate a history of this woman having slipped and fallen on rocks while crossing a creek. Of course, the claimant’s injury attorney had difficulty explaining this away.

Proportionality between claimed injury and bills

One prime aspect that insurance adjusters look for in any claim is a sense of proportionality between the injuries claimed and the extent of medical bills incurred. Adjusters develop a “sixth sense” as to when the medical bills are out of alignment with the nature and severity of the injury. Soft tissue injury claims, in particular, are prime candidates for “build up,” a term of art among adjusters meaning the phenomenon of artificially inflating the amount of medical bills incurred, in order to artificially inflate the perceived settlement value of the claim.

Correlation between the medical records and treatment received

Adjusters become suspicious if the medical bills submitted by your personal injury attorney lack the necessary corresponding medical reports. The reports validate the diagnosis made, treatment given, and future prognosis. If the personal injury attorney does not include a medical report for each bill, the adjuster may discount — or even disregard — those particular charges.

In medical malpractice litigation, it is often said, “If it’s not in the chart, it didn’t happen.” Some bodily injury adjusters take the same approach to evaluating medical expenses: if there’s not a medical report to go along with the bill, it isn’t worthy of consideration.

Complete records and supporting documentation

Adjusters do not — and will not — evaluate claims on the honor system. It’s not a matter of whether they trust you or not; it’s their job to question everything and view personal injury claims with a healthy dose of skepticism. If a settlement demand includes charges for which your personal injury lawyer has not presented the supporting documentation, an adjuster may wonder what other areas of the claim are soft, suspect or padded.

When your personal injury attorney provides the adjuster with a breakdown of expenses in a cover letter or settlement notebook binder, the attorney must be sure that there is also a copy of that bill in the supporting documentation. Most adjusters will conduct this type of reconciliation and verification. If a bill is referenced, but no such bill is produced, the adjuster will not give that number much weight or credence.

Another aspect of a claim that may draw an adjuster’s raised eyebrow are medical reports that appear to be run off of a word processor, often with only the patient’s name changed. Fill-in-the-blanks medical reports also garner an adjuster’s skepticism. Adjusters become accustomed to seeing medical reports from the same health care providers over and over again and develop a “book” or perspective on certain doctors and their medical practices. When a claim is presented with one of those doctors as the treating physician, the red flag can be raised in the adjuster’s mind.

Lost wage documentation

Suppose you were out of work for three months with a soft tissue injury sustained in a slip and fall accident. Your personal injury attorney has obtained a statement from your employer verifying that you missed work. Your personal injury attorney must also obtain documentation of your lost wages. Without that documentation, expect the adjuster to haggle over this aspect of the settlement demand and discount most of the lost wages.