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Is my medical treatment limited by the insurance adjuster?

Insurance adjusters are not qualified to make decisions regarding your medical treatment. Only a licensed physician can do that. However, while insurance adjusters cannot limit the scope of your treatment, they will try to limit compensation for your injuries using tactics designed to undermine your case. The ultimate goal of any insurance adjuster- whether working for you or the defendant- is to limit damages paid to the injured party to protect the profitability of the insurance company. This is why you should know what the adjuster is looking for and how to strengthen your case.

What do insurance adjusters look for?

An insurance adjuster essentially investigates a personal injury claim, calculates compensation, and makes settlement offers. They consider a number of factors to determine liability and compensation, including:

  • Actual expenses: past, present, and anticipated medical bills and costs related to your injury.
  • Actual losses: wage and income losses based on your inability to work.
  • Pain and suffering and emotional distress damages: actual expenses and losses are a matter of simple addition. Pain and suffering is more subjective. Insurance adjusters generally apply their own formulas to determine damages, such as a per diem system using a predetermined amount paid per day of suffering or a pain multiplier system.
  • Policy limits: insurance companies will never pay beyond the maximum liability coverage. For instance, if the policy maximum for liability compensation is $100,000, the insurance company will only make a payment up to that amount. If your damages exceed that limit, you would have to file a civil suit against the defendant who would pay out-of-pocket for the remaining costs of your injuries. However, most defendants would file bankruptcy which would wipe out the excess claim.
  • Strength of your case: based on the evidence, the adjuster will predict if you can win in court. Trials are generally high risk for insurance companies because a sympathetic jury may award higher damages than what may have been offered in a settlement. In some jurisdictions the juries are very conservative and really do not reward much for pain and suffering; this will be reflected in the settlement offer. Generally, the greater the likelihood of success, the higher the settlement offered.

Tips to strengthen your personal injury claim

Remember the goal of any insurance adjuster is to undermine your claim. They will attempt to gain access to your full medical history and pay conservative doctors to conduct an independent medical examination (IME) to discredit the severity and cause of your injuries. Here are some tips to maximize the likelihood of receiving the compensation you deserve:

  • Evidence is the foundation of any successful claim. You should collect all medical bills, medical records, photos, and wage verification documents related to your injury and file them in chronological order.
  • Take copious notes on any interactions or correspondence with the insurance company or at-fault party.

Insurance adjusters can indirectly limit the medical treatment you receive by diminishing payouts needed for necessary ongoing and future treatments. A skilled personal injury lawyer will know the worth of your claim and can fight on your behalf to get you the settlement you deserve. If you need a lawyer to aggressively advocate for your right to compensation, call Crane Flores, LLP anytime, day or night, at (805) 628-4967.