How Insurance Adjusters Use Medical Records to Reduce Your Settlement

Hi, my name is Joe Moses. I’m a founding partner in the law firm of Kass and Moses. We’re a personal injury law firm that represents injured motorcyclists and we’ve done so for the last 30 years. Many of my clients want to know more about how insurance adjusters use the medical records to try and reduce the value of a settlement. And that is what I’d like to discuss with you in this video.

In most cases, your medical bills are the primary basis for valuing your claim. So for that reason, the insurance adjuster will closely scrutinize your medical records, looking for ways to reduce your claims value. In particular, adjusters will look for the following seven red flags in your medical records.

Red flag number one. Are your medical bills proportional to your claimed injuries. So insurance adjusters look for consistency between the injuries that you’re claiming and the medical bills incurred. Adjusters develop a sense as to when the medical bills are out of alignment with the nature and severity of your injuries. For instance, soft tissue injury claims also called whiplash or low back pain are primary candidates for building up. Buildup is a term of art among adjusters, which refer to the act of increasing medical bills incurred to artificially inflate your settlement value. So this done by treating excessively for an injury, physical therapy treatments that continue on and on with no reduction in weekly visits and no appreciable improvement. These things are always suspected.

Red flag number two. The type of treatment that make up the bills. In addition to the amount of your medical bills, the source of those bills will be important to the adjuster. In the eyes of an adjuster, a two week hospital stay, and three months of formal physical therapy are much stronger evidence of an injury than a few thousand dollars worth of x-rays, diagnostic, test and chiropractic treatment.

Red flag number three. Do your medical records suggest a lack of causation? Do your records include a notation about prior claims or injuries? Is there a mention of preexisting conditions or injury to the same body part? Is there any reference to intoxication alcohol or drugs? Does anything in your medical records deviate from the official description of the accident that has been represented to the adjuster?

Red flag number four. Is there a correlation between the medical records and treatment received? Adjusters become suspicious if the medical bills submitted lack corresponding medical reports. Those reports are considered by the adjuster to validate the diagnosis made, the treatment given in your future prognosis. If a medical report does not accompany each set of bills, the adjuster may discount or even disregard those changes. In medical malpractice litigation it’s often said if it’s not in the chart, it didn’t happen. Some adjusters take the same approach to evaluating medical expenses. If there isn’t a medical report to go along with a bill, it isn’t worthy of consideration.

Red flag number five. What is the quality of the medical information provided? Fill in the blank medical reports are viewed with skepticism. Narrative reports from well respected doctors explaining the nature of your injuries in descriptive detail are best. Hospital records with detailed nurses notes are also excellent sources of information on your injuries.

Red flag number six. What did you tell your first doctor you saw after the accident? Expect the adjuster to scrutinize the medical record of the first caregiver. Focusing on the history given. If that history says nothing about an accident or attributes the injuries to a preexisting condition, expect that the adjuster will argue that your injuries are not related to the accident. Additionally, if the initial doctor visit fails to mention accident-related pain in a body part that you later complain about, it will be scrutinized.

And finally, red flag number seven. What is the reputation of your treating doctor? Is your doctor known for specializing in treating patients with insurance claims only? Does your doctor advertised for personal injury victims? If so, the doctor’s credibility will be suspect, as will the validity of your claim.

So to recap, are your medical bills proportionate to the claimed injuries? What type of treatment did you receive? Did your medical records suggest a lack of causation? Is there a correlation between the medical records and the treatment received? What’s the quality of the medical information provided? What did you tell your first doctor you saw after the incident? What is the reputation of your treating doctor?

We consider it our job to guide you in your treatment and the communication with your doctors. The sooner you call the sooner we can advise on this and any other matter. As always, there are no bad questions. We’re available to discuss your situation anytime. Call me at 1-800-MOTORCYCLE.