Florida personal injury and medical malpractice lawyer, Guy S. DiMartino, DC, JD, discusses how insurance adjusters evaluate a Florida personal injury claim.
In a recent post on Property and Casualty 360, an insurance industry online journal, we get an inside look into an insurance adjuster's evaluation of a personal injury claim.
When doing due diligence, taking the additional time to research all possible scenarios is time well spent. This is especially true for injury claims, where a few critical building blocks can be the difference in millions of dollars annually. Consider the following:
Police report. Was there any mention of injury at the scene? Which parties were cited as well as listed for contributing factors, which often don't result in a citation. These facts are critical for establishing both liability and damages.
The insurance company wants to use the police report to take the position that the client was not injured –because they didn't complain of injuries at the scene of the accident or didn't go to the hospital by ambulance. This is not a strong talking point for the insurance adjuster if the client has sought medical attention within 48 to 72 hours after the accident.
Vehicle photographs (auto claims). Does the damage match? Are there paint transfers? What is the directional force of impact? Was there a mechanism for injury?
Insurance companies know that juries have difficulty giving money to people who claim injury in a car accident when there is a small amount of property damage.
Accident scene. Are there any other potential tortfeasors? Overgrown bushes, signal outages, missing or blocked signage, absentee third parties, and so on.
The insurance company is looking to shift responsibility to another party and save itself some money.
Emergency Room records. What does the admission statement say? What type of pain was related to the treating physician? Was there a mention of symptoms other than what may be related to the accident? Is there evidence of a pre-existing condition or intervening cause?
Insurance companies know that emergency room records are not complete and most of the time they deal with the most pressing problem so they like to use information not contained within the emergency room record to argue that the client did not get that injury in the accident.
Treatment patterns. How soon did treatment start? Were there gaps? Was there treatment on evenings and/or weekends?
Insurance companies know that juries hate gaps in treatment. An initial gap in treatment gives insurance company ammunition to say if the client was really hurt in the accident – they would have seen a doctor sooner.
Gaps in the middle of treatment gives the insurance company ammunition to take the position that the client made her condition worse or didn't get better like she should have because there were gaps in treatment and she didn't follow the doctor's advice.
Provider type. Was the claimant seen by a chiropractor or medical doctor. If the latter, then what was the specialty? What are their credentials? Are the licensures current? Are there any prior or pending disciplinary actions with their current state, or prior states?
Insurance companies take the position that the injury is minor if there is only chiropractic treatment. If the treating physician has other issues, the insurance company can use it as a talking point.
Duration and frequency. When did treatment start? How long did it last? Was it active or passive? Was it longer than an anticipated expected recovery date among the general population for a similar complaint?
This is the same discussion as GAPs in treatment.
Objectivity. Were there objective findings, such as those from an x-ray, MRI, or CT scan? Were the records and films obtained and reviewed by an independent medical expert?
Insurance companies routinely send imaging studies out to their doctors, who they like to say are independent. These radiologists typically disagree with the patient's doctor's interpretation. Pain Management. Did the doctor prescribe medication to ease the complaints of pain? What type (analgesics, prescriptions, injections)? Did the injury have any impact on the claimant's lifestyle?
Insurance companies like to take the position that the injuries were minor if the doctor did not prescribe pain medication or the patient did not take pain meds.
“SOAP” Notes. Does the treatment being charged match the medical providers' subjective, objective, assessment, plan (SOAP) notes? These notes can often provide a great indicator of not only what treatment really occurred, but also a red flag for CPT coding modifier abuse. These can be a great source for identifying upcoding, unbundling, or other deceptive medical billing practices.
Recently, insurance companies have been challenging the medical treatment performed by doctors. Taking the position that the doctors have a bias because they can bill more for accident cases.
This guideline from the insurance industry's own mouth gives the injured person a good guideline as to how the insurance adjuster will attempt to limit the amount of money they pay for a claim. It all starts with the initial statement above – it can make the difference in millions of dollars.
If you have any questions about Florida personal injury claim, contact Dr. Guy S. DiMartino, DC, JD at (352) 267-9168 or fill out the internet consultation form on the right hand side of the screen.