Educate your patients on how to get the most out of personal injury insurance claims

While working for more than 30 years in the insurance industry as an adjuster, supervisor, manager, and trial assistant, I found chiropractors to be honest and straightforward health care practitioners concerning personal injury (PI) insurance claims. As such, I am sharing my experience and knowledge on the ins and outs of the industry. The following insights will provide chiropractors with a greater understanding of how to assist their patients with PI claims. When word spreads how helpful and instrumental you were in working with insurance companies, your new patient base will increase.

Covering Your PI Bases
The job performance of insurance adjusters is judged on the dollar amount spent in settlement and the time it takes to bring assigned claims to a conclusion. Adjusters will never admit to it, but the weight of their caseload and time constraints are favorable to patients. It is an advantage most chiropractors or their patients are not even aware exists.

Medical bills. The value of a claim has a direct relationship to the amount of medical bills. Why? A claim with medical bills of $500 to $700 is worth three to five times more than a claim with $200 or less in bills—and this is a fact of life in the world of insurance claims.

For example, an adjuster will reason that if your patient was hurt badly enough to run up $700 in medical bills, then it is correct to assume that injuries must be substantial. But, if the patient has seen you only once or twice and the final bills are $100 to $200, the adjuster will assume your patient was not seriously hurt.

Whiplash injuries. Whiplash is a convenient way of designating certain accident injury facts that produce pain in the cervical area. As most of you well know, the term carries no medical connotation, but whiplash-type injuries can be extremely painful and last for a long time.

It is important that your patients are aware that because of the misuse of the term whiplash, most adjusters are suspicious when someone claims whiplash as an injury. Those involved in the business of insurance claims, including adjusters, supervisors, managers, and defense attorneys, will not admit to it, but from my experience, I have found it to be true.

Without question, there are often severe injuries involving the cervical region of the spine. To many in the insurance industry, whiplash is a medical smoke screen used to confuse, delude, and defraud. You must provide specific details regarding your patients’ whiplash-type injuries.

When it comes time to settle a claim, your patients must be in a position to stress their injuries as being authentic. To do this, there must be a detailed medical report that clearly describes the whiplash-type injuries. Your patients should not fall prey to being blackmailed or convinced into lessening the severity of their injuries. If this report is dealt with correctly, it is worth its weight in gold to your patients.

Medical reports. Provide your patients with their medical reports, which are crucial for a successful settlement of a bodily injury claim. The record should cover the recovery time of total disability, recovery time of partial disability, inability to perform certain functions, and the existence, possibility, or probability of permanent and/or disabling effects.

Examination by insurance company doctors. Adjusters may insist that your patients be examined by a doctor of the insurance company’s choice. Your patients should beware of such a request. Doctors selected by insurance companies are notorious for finding nothing wrong with the patient, which suggests the complaints are without justification. Such doctors—who are paid by the insurance company—will invariably report in writing their failure to find any symptoms that they could physically see and/or specifically measure.

Make your patients aware that they do not have to agree to be examined by the insurance company doctors. They are entitled to continue visiting and be treated by chiropractors of their choice. Insurance companies can only require their own examination when a claim becomes a formal court case involving a trial. By that time, it may be too late for your patients to get involved in the medical report con-job insurance companies may attempt to pull.

Value of photographs. I cannot emphasize enough the positive value of color photographs of an injury to insurance claims. Photos of cuts, bruises, and swelling taken at a close range from different angles and enlarged to 8x10 format are important additions to claims. They can be dramatic and, more often than not, add substantially to settlements.

When these photos are given to adjusters, they will blanch because they know the positive impact such photographs will have if the case ends up in the hands of a judge or jury. The dollar value of such photographs is immeasurable.

Lost time and wages. The days and hours your patients are unable to function at work should not be considered as time away from work because of an injury strictly as lost time and earnings, but rather as lost earning capacity. In many instances, patients can claim lost time and earnings, even if they had no actual loss out-of-pocket—for example, when their salary is paid because they have taken sick leave, or because of an accident and health policy.

If patients have to take sick leave or vacation pay during the period they missed from work, that must be considered. They must keep in mind that they would have been entitled to use that sick leave or vacation time for other periods when they needed or wanted it. If they were forced to take sick leave, or vacation time, because of an accident, it is considered the same as losing the money itself.

Commissions and overtime are legitimate losses they can claim. They should obtain a letter with an official letterhead from their employers detailing the approximate amount of money lost in commissions and overtime. This can be accomplished by reviewing the previous year’s figures for the same period and then averaging them out for that identical time they were unable to work.

If patients are self-employed or business owners, they must be sure to collect for the cost of additional help they had to hire while undergoing treatment and during recuperation. To substantiate their claim, they should provide the adjuster with documents proving a loss in billing or services, a calendar showing canceled appointments, and letters or documents regarding unattended business meetings.

If the adjuster attempts to disallow your patients’ gross wage loss figure or certain kinds of wage-related expenditures declared (some states differ), your patients should demand that the adjusters cite their legal authority and quote or produce specific court decisions, legal precedents, or statuary texts in the state in which the accident took place that gives them legal justification. In most instances, they will not be able to do so.

If adjusters fail to cooperate, your patients can always go over their heads to the direct supervisor. This works more often than not. Should your patients decide to do this, they will need the following information: the claim number, name of the other party, name of the adjuster, and other relevant information the claims supervisor may need to locate the file. Tell your patients when calling the insurance company, ask the operator for the adjuster’s supervisor. This should be enough information for the operator to locate the proper person.

Small claims court. If all else fails in working with an adjuster, your patients can file a claim in small claims court, often referred as the “user-friendly” court. The award amount the court can grant is limited by state statutes, so have your patients check this out before proceeding.

Daniel G. Baldyga resides in West Springfield, Mass, and brings his experiences as a private detective and criminal investigator in the US Navy to a 30-year career working in the insurance industry as an insurance adjuster, supervisor, manager, and trial assistant. He has written many insurance books, including, How to Settle Your Own Insurance Claim, Secrets Never Told, and Auto Accident Insurance Claim. Baldyga can be reached via his website: www.autoaccidentclaims.com. 

This article is to help people understand the motor vehicle accident claims process. The author does not makes guarantees of any kind whatsoever and does not purport to engage in rendering any professional or legal service, or substitute for a lawyer, an insurance adjuster, claims consultant, or the like. Where such professional help is desired, it is the individual’s responsibility to obtain it.