The Insurance Investigation of Your Personal Injury Claim

Once a claim file is opened, the insurance adjuster will go over the details of your personal injury case with a fine-tooth comb.

The first thing that an insurance company will do after hearing about a potential injury claim is to open a file. Either the insured or the injured person might report the claim to the insurer. Once the insurer opens a file, the insurer will assign it to a claims adjuster. The adjuster is the person who will investigate the facts of an accident and negotiate a settlement of the claim.

In the insurance context, the word “adjust” means to determine or settle a claim or to assess a loss or damage. Many insurers use “in house” adjusters, meaning that the adjuster is employed by the insurer, but some insurers like to hire outside claims investigation services to handle the investigation and settlement of the claim.

First Things First: What Does the Insured Say?

The first thing that the adjuster will do is find out what the insured says. Experienced adjusters may not always believe their insured, but they do want to know what the insured says. They know that simply because the insured says that the light was green does not mean that it was green.

So, the adjuster will read the insured’s written accident report that was submitted to the insurance company (if the insured sent one), and will often call up the insured to hear what he/she has to say.

Requesting Official Records

The adjuster will request whatever official records might exist. In a car accident, the adjuster would request the police report and the accident reports that the drivers filed with the state department of motor vehicles, if such documents exist. The police are not called in every accident, and not all drivers submit accident reports to their department of motor vehicles.

Responding to the Claims

If no one files a claim, the adjuster has nothing further to do. Adjusters do not seek out the injured persons and ask them if they are going to file a claim.

But once the claim comes in, the adjuster will usually respond with a generic letter that identifies him/herself, provides the applicable policy limits (if the accident occurred in a state that requires the insurer to provide the policy limits), and asks the claimant or the lawyer to provide all documents relating to the claimant’s damages, such as medical records, medical bills, proof of earnings, and proof of property damage.

Investigating the Injured Persons

Adjusters want to know who they are dealing with. They want to find any negative information on you that might lower the value of your claim. So they will check the proprietary insurance claims databases to determine whether you have ever filed a personal injury or property damage claim before. They will also get on Google and Facebook, among other places, to check you out.

If you claim to the insurer that you hurt your back in a car accident on May 12th, but your Facebook page says that you competed in a week long ice hockey tournament, without any mention of a back problem, beginning May 14th -- or, worse, that you fell down the stairs on May 11th -- the adjuster is going to be pretty skeptical about the validity of your car accident claim.

Medical Authorizations

Medical records are critical in a personal injury claim. The adjusters spend a lot of time and energy making sure that they have all of the relevant medical records and bills. Further, adjusters never trust plaintiffs or their lawyers to send them all of the records; they always prefer to get the records themselves.

So they will send the injured person a medical authorization that will allow them to request the medical records themselves. Do not sign such an authorization unless your lawyer tells you that you should. If you do not have a lawyer, do not sign a medical authorization for the insurance company. Different authorizations authorize different things, and you do not want insurance companies requesting twenty years’ worth of your medical records or talking to your doctors on the phone.

The Adjuster Will Ask You for a Recorded Statement – Don’t Do It

Insurance adjusters will usually ask that an injured person give a tape recorded statement describing the accident and his/her injuries. As a general rule, giving such a statement in a car accident case will not help you if you do not have a lawyer. If you do not have a lawyer, you should not give a tape recorded statement to the insurer no matter what the adjuster says.

The Adjuster Will Determine the Value of the Case and Negotiate a Settlement

Once the adjuster has all of your medical records and bills and all of the other information that he/she needs to value the case, he/she will put a value on the case and try to settle it. If you don’t have a lawyer, the adjuster will generally ask you how much you want to settle the case. Don’t give a number first. Ask the adjuster how much he/she will offer to settle. Then you have to negotiate.

Negotiation is not easy. If you were in an accident and have any questions about what the insurance adjuster is doing in your case or are having any problems trying to settle the case, you should contact a personal injury lawyer.

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