What Insurance Adjusters Consider When Evaluating Claims

How Do Insurance Adjusters Decide On a Settlement?

insurance adjuster speaking with man about car insurance policyWhen adjusters evaluate how much your claim is worth and what they are willing to offer, they will generally take into consideration the following items:

Proportionality between Medical Bills and Injury

Insurance adjusters take a close look at the proportionality that exists between the medical costs incurred and the claimed injuries. If the severity and nature of an injury do not align well with the medical bills, an adjuster’s “sixth sense” will raise alarm bells. In particular, adjusters are sensitive to “build up” in soft tissue injury claims, which is the practice of inflating medical costs in an attempt to increase a claim’s settlement value.

Causal Relationship Existing between Medical Records, Injury, and Accident

When examining the claim for damages presented by a claimant, insurance adjusters will closely examine all medical records they receive looking for:

  • Documentation of a pre-existing condition or injury to the same part of the body;
  • Documentation of intoxication, drugs, or alcohol;
  • Note of prior injuries or claims;
  • Medical opinion(s) that support a claim of scarring or permanent injury;
  • Medical opinion(s) that support the claimed length of disability; and
  • Any reference in the medical record that is different from the “official” accident account the adjuster received.

For instance, a claimant may allege he injured his back when he fell off a medical examining table. He maintains the table was defective and asserts a claim for product liability. However, the medical records sent to the insurance company make no mention of a fall off an examining table but do mention the claimant had fallen on slippery rocks while walking across a creek. Naturally, you would have a difficult time explaining this discrepancy.

Contact Canan Law Today for Help

A personal injury lawyer can help you understand what insurance adjusters are looking for when examining personal injury claims.

If you would like to speak with an experienced and knowledgeable lawyer in St. Augustine, please contact Patrick Canan at (904) 849-2266 and request a free consultation.


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