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Decoding the Process: How Insurance Companies Evaluate Personal Injury Cases

Personal injury cases are intricate webs of legal, medical, and financial intricacies, and insurance companies play a pivotal role in determining the outcome of these cases. Understanding how insurance companies evaluate personal injury cases can provide insight into the factors that influence their decisions and empower individuals navigating such situations.

1. Initial Assessment:


When a personal injury claim is filed, the insurance company initiates an assessment process. This involves gathering information about the incident, including police reports, medical records, witness statements, photographs, video and any other relevant documentation. The insurance company will look at liability, who caused the accident, and if it is an automobile accident, the extent of the property damage. Even though property damage has no direct correlation with injury, the insurance companies know, if there is little visible property damage, a jury will have a hard time believing that the individual was injured from the crash.


2. Extent of Injury:

The severity and extent of the injury significantly impact the evaluation process. Insurance adjusters scrutinize medical records, diagnostic tests, and physician assessments to ascertain the nature of the injury, its prognosis, and the potential long-term implications. The adjuster will run background checks to see if you were involved in prior accidents with claims to determine if your injuries are pre-existing in nature and possibly aggravated from the accident at issue, or if they are new injuries. The adjuster shall also look to see if you follow your treating doctor’s advice regarding medical treatment and whether your treatment is conservative in nature or if you have undergone injection therapy or possibly surgery.

3. Medical Expenses:


The incurred and anticipated medical expenses form a crucial component of the evaluation. Insurance companies meticulously review medical bills, treatment plans, and healthcare provider invoices to determine the financial impact of the injury. Even though your doctor may suggest a future surgery, the insurance company shall place little value on what may happen in the future, they only consider what treatment actually took place prior to the date of settlement.

4. Lost Wages and Income:


Personal injuries often result in missed workdays or even long-term disability, leading to a loss of income. Insurance companies evaluate the documentation provided by employers, such as pay stubs, employment records, and tax returns to quantify the economic repercussions of the injury.

5. Pain and Suffering:


Compensation for pain and suffering is subjective and challenging to quantify. Insurance adjusters consider various factors, including the severity of the injury, the duration of recovery, the type of medical treatment rendered and the impact on the individual’s quality of life, to assess non-economic damages. There is no precise way to evaluate pain and suffering damages, it is performed on a case by case basis.

6. Comparative Negligence:

In cases where fault is disputed or shared, insurance companies conduct investigations to determine the degree of comparative negligence. In the State of Florida, based upon the new law passed in March of 2023, if the Plaintiff is deemed more than 50% at fault, he/she is NOT entitled to any compensation for his/her claim.

7. Precedents and Case Law:

Insurance companies rely on past legal precedents and case law to inform their evaluation process. They assess similar cases and their outcomes to establish a framework for negotiating settlements. The insurance companies have data bases full of claims with similar injuries and settlement figures to help determine the value of each claim.

8. Negotiation and Settlement:

Once all pertinent information has been gathered and evaluated, insurance adjusters engage in negotiations with claimants or their legal representatives. The goal is to reach a mutually agreeable settlement that adequately compensates the injured party while mitigating financial risk for the insurance company.

9. Litigation:


If negotiations fail to yield a satisfactory resolution, the case may proceed to litigation, the filing of a lawsuit against the at fault party. Insurance companies weigh the potential costs and uncertainties associated with litigation against the prospect of a favorable outcome in court. Besides the facts of the case, the insurance company will also look to see who the attorney is who is representing the Plaintiff, as the insurance company keeps track on which attorneys will take a case to trial and which attorneys will only settle cases.

10. Resolution:


Whether through settlement negotiations or litigation, the ultimate resolution of a personal injury case involves the payment of compensation to the injured party. This compensation aims to cover medical expenses, lost wages, pain and suffering, and any other damages deemed appropriate by the courts or agreed upon through negotiation.

In conclusion, insurance companies evaluate personal injury cases through a multifaceted process that considers medical evidence, financial implications, legal precedents, and negotiation dynamics. Understanding this process can help individuals navigate the complexities of personal injury claims and advocate effectively for fair compensation. If you are involved in an accident resulting in injury, call the attorneys at Hicks & Motto, 561-683-2300
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