How Insurance Companies Evaluate Serious Injury Claims

It’s common to wonder how an insurance company will evaluate your claim if you’ve been seriously injured. From serious car accidents to slip-and-fall injuries, the goal is to scrutinize your claim. It can leave you feeling like you need to prove your injury at a time when you’re already overwhelmed by the healing and recovery process. Here’s what a personal injury lawyer wants you to know about how insurance companies evaluate serious injury claims.

1. Determining Responsibility

Prior to putting any kind of dollar amount on a claim, an insurance company needs to determine who they believe is responsible for an accident or injury. The first task is simply determining if the policyholder is at fault.

In cases where there are multiple contributing factors, the insurance company’s role becomes determining what percentage of fault can be assigned to the policyholder. If it can be proven that the victim shares some of the responsibility for the serious injury, the value of the injury claim can be reduced based on how much fault is shared. This is why focusing on establishing liability for the other party early on is critical when you need compensation that will enable you to recover from an injury and maintain quality of life.

Insurance companies don’t rely on guessing games to determine who is at fault. They are required to use concrete and verifiable evidence. If you’ve collected and saved evidence related to your injuries that proves your side, this can work to your advantage substantially. Insurance adjusters strongly consider these pieces of evidence:

• Police reports
• Incident reports
• Documentation or citations that prove neglect
• Initial victim and witness statements
• Video or photographs

In many cases, you may already be in possession of evidence that makes your case. In other cases, an investigation is needed. You may need to work with lawyers to collect evidence from witnesses or ask to access evidence that the person responsible for the injury may be holding. 

2. Evaluating Your Medical Care

When you’re the victim in a personal injury case, the opposing side’s insurance company is going to look closely at your medical records and treatment. The authority of doctors and other care providers can carry a lot of weight in personal injury claims. Being evaluated right away and following treatment protocols can significantly help a victim’s case. An insurance adjuster is looking for any proof that your behaviors show that an injury is not that serious. This means they’re looking for any gaps or delays in your care that can demonstrate you were able to easily manage symptoms without help.

Treatment dates also matter. For example, an insurance adjuster may scrutinize a decision to wait weeks or months to seek care following an injury. Skipping appointments can also raise questions. Even medical records dated prior to an injury can be used to evaluate the seriousness of a victim’s injury. This is where many adjusters will try to use preexisting conditions to raise questions about when exactly symptoms started.

3. Examining Proof of Physical Limitations

Adjusters also want to see proof of how an injury is impacting daily function and quality of life. Has a person been able to return to their job? Can they resume normal household and parenting duties? This can be one of the most challenging aspects of a personal injury case because many injured people have no choice other than to push through the pain and suffering in order to maintain an income or take care of their families. However, documentation like notes from doctors and disability records can help to strengthen a case and help you obtain damages in motorcycle accidents if you were riding a motorcycle at the time of the crash.

4. Determining Severity

While it may be easy to prove that there is an injury, proving that it has long-term effects can be more challenging. Insurance adjusters look at things like the cost and duration of medical treatment, implications for a person’s ability to work, and the potential costs and losses associated with long-term disability stemming from injuries. The evidence used for this phase includes things like medical records, bills, and HR records detailing work absences or medical leave from your employer. When you can prove that you need long-term medical intervention, you are more likely to receive a larger compensation amount.

5. Assigning a Dollar Figure to a Personal Injury Claim

Ultimately, all of the investigation steps to a personal injury claim come down to putting a dollar amount on what you are owed. This is where adjusters factor in liability, cost of medical treatment, and all past and future medical bills and income losses stemming from an injury. Victims can also request additional compensation for losses that aren’t as easily calculated. This includes reduced quality of life, loss of enjoyment, ongoing pain and suffering, and emotional distress.

Making Your Voice Heard: How to Make Serious Injury Claims Smoother

For those who have been hurt, feeling like you need to prove the seriousness of your injuries can be insulting. It can also feel overwhelming at a time when recovering and adjusting to a new quality of life are your main concerns. However, it’s important to know that power isn’t solely in the hands of insurance adjusters. Acting quickly, keeping detailed records, and documenting ongoing suffering can all help to prove to adjusters that you deserve the maximum payout allowed. The first step is establishing liability for the other party by removing all doubts about your actions or behaviors.