How Are Insurance Claims Evaluated?

How insurance companies evaluate personal injury cliams

Insurance Companies Are Smarter Than You

Insurance companies know a lot more than you do about how insurance claims work. They also exploit your lack of understanding to take money out of your pocket.

When you are injured, say in a motor vehicle crash or a slip and fall, you file a claim against the party responsible, who turns it over to their insurance. Invariably, many people talk to the insurance adjuster and provide a recorded statement. Even an innocuous seeming question like "how are you feeling today?" can be a hidden landmine. If you answer that, "I feel better than yesterday," you’ve just allowed the adjuster to devalue your claim. Low and behold, when you claim months of pain and suffering, the adjuster points to your statement as a reason why you were improving already and that the subsequent medical treatment was unnecessary.

Insurance Companies Know the Lingo and You Don’t

While many are familiar with terms like "pain & suffering," unless you are a lawyer, you probably do not understand what it means in the legal context, how to prove it, what evidence helps to do so, or how to maximize its value in a claim or trial. In other words, how can you argue what something is worth if you don’t understand how that term is defined or how you would prove it at trial?

Insurance Companies Have Massive Data Resources

Virtually every major insurance company has its own proprietary computer program to evaluate medical bills, injuries, amount of treatment, reasonableness of demands, and predicted verdicts. Some even have special names and acronyms, like Colossus.

Why It Matters

When you send in your bills for your medical treatment, the insurance carrier already knows whether your doctor is a reliable witness, whether he or she overbills or has been suspended, knows whether you have filed another insurance claim previously, and is able to run this all through a sophisticated program. The program and the adjuster will even scrutinize billing codes for services, commonly known as HCFA, to determine valuation of the claim, whether the treatment and cost of it will be deemed "reasonable."

Insurance Companies Are Experts at Insurance Claims and You Are Not

When you make a personal injury insurance claim, it is assigned to a claims adjuster. Even the least experienced adjuster will have several hundred active claims at any one time. He or she also will be part of a department or group filled with dozens of others who also have several hundred claims pending. They meet regularly, hold committee "roundtables" to evaluate and discuss claims procedures, and have a hierarchical organizational structure that provides them plenty of expert help and advice in handling these claims. If you are assigned to a claims adjuster who has been working in auto injury claims for ten years, that person alone might have handled as many as 10,000 claims just like yours. Do you really think this is a fair fight?

Help On Your Side

If you're injured in a car crash, slip and fall, or other incident, consult a lawyer immediately to determine how to handle the insurance companies. Attorney Stephen Hoffman has been representing injured parties for over 25 years. Contact the Law Office of Stephen L. Hoffman today to schedule a free consultation: call (773) 944-9737 or email

Categories: General