When you have suffered an injury through no fault of your own, your own and someone else’s insurance will likely pay for at least some of your medical care, unplanned expenses, pain, and suffering. Various forms of insurance can come into play, including auto liability, commercial liability, health, and long-term disability coverages.
But insurance companies do not automatically pay personal injury claims. Instead, they investigate those claims first to make sure they owe the amount claimed under their policies.
Here’s an overview of why and how insurance companies investigate injury claims and of the ways an experienced personal injury attorney can help make sure an insurance company treats you fairly and pays you the maximum amount available for your injuries and losses.
What is an injury claim for an insurance company?
When it comes to seeking compensation for a personal injury, most people tend to use the word “claim” pretty broadly. They usually understand it to refer to any rights to demand payment from someone else for the expenses, losses, and damages they suffered in an accident. An injury claim could be an informal demand written by a lawyer, a formal lawsuit, documentation submitted to an insurance company, or some combination of them.
But for insurance companies, an injury claim is specific. It’s a request for payment of injury-related expenses made to an insurance company under the terms of an insurance contract (policy), either by the insurance company’s customer (policyholder) or by someone else (a third-party) claiming to have rights under that policy.
A claim triggers a process by which the insurance company evaluates the facts and the policy’s terms to determine whether and how much it must pay the claimant.
Why do insurance companies investigate injury claims?
Insurance companies investigate injury claims to make sure they genuinely owe money to the claimant. Its business depends on only paying valid claims under the terms of its policy. An insurance company cannot stay in business if it frequently pays invalid or fraudulent claims, and investigating claims is one way to avoid doing that.
The less money insurance companies pay out on valid claims, the more profit they stand to earn. So, insurers investigate claims to validate them and find reasons to minimize any amount they might owe. Unfortunately, this often gives insurance companies and their employees a strong incentive to conduct aggressive investigations and sometimes to engage in unfair and illegal claims handling practices.
Variations in Claim Investigation Practices
All insurance companies investigate claims to one degree or another. Still, the scope and nature of their investigations can vary depending on the type and amount of insurance involved in a claim.
Take, for example, a two-car accident caused by Driver A’s negligence, in which Driver B suffered severe injuries, and both vehicles sustained significant damage. Multiple types of insurance could pay some portion of the costs and losses in this scenario.
- Both drivers will usually carry auto insurance that, at a minimum, covers their potential liability for causing someone else’s injuries and vehicle damage in a crash, and which may also cover their injuries and vehicle damage;
- Both drivers will also often carry health insurance that may pay (at least initially) for their medical care for accident-related injuries;
- If either driver crashes a work vehicle while on the job, that driver’s workers’ compensation insurance may pay for some medical care and lost wages, and that driver’s employer may carry commercial liability insurance to cover damages the driver’s actions caused.
Because any of the insurance companies above may need to pay for some accident-related expenses, any of them might investigate what happened. But some may have more reasons to investigate than others, depending on how much money is at stake for them, the terms of the policies they issued, and whether the person claiming payment is their policyholder (as is common for health insurance) or someone their policyholder harmed (as is common for auto liability insurance).
In any given car accident case, it’s not uncommon for some insurance companies to pay claims without putting up a fight, while others conduct searching investigations hoping to find reasons to refuse payment.
Overview of Liability Insurance Claim Investigation
In the aftermath of an accident that causes personal injuries, the parties involved-both the victim and at-fault party-will often contact their own insurance companies to let them know what has happened.
Auto and other liability insurance companies, in particular, require notification from their policyholders, because (among other reasons) it allows them to begin a prompt investigation and to account for their potential financial exposure for accident-related damages.
Here’s an overview of how a typical accident liability insurance claim investigation unfolds.
#1. Opening of a Claim File and Assignment of Adjuster
Upon receiving notice of an accident that has caused injuries and losses potentially covered under a policy they have issued, insurance companies typically open a claim file and assign it to an employee or department responsible for handling the claim evaluation and payment process. In insurance-speak, this process is claims adjusting, and the employee assigned to handle a claim file is called a claims adjuster.
Insurance companies commonly open claim files and assign adjusters even before a policyholder or other party covered under the policy submits an actual claim for payment. In other words, an investigation of an injury claim can-and frequently does-begin even before the claim formally exists.
#2. Initial Investigation
Having received a claim file, the adjuster begins to gather information about the accident, the injuries it caused, and the potential costs and losses that the insurance company might have an obligation to pay.
The adjuster may, for example:
- Contact the policyholder to follow up on the policyholder’s initial notification, provide guidance on the claims process, ask questions about the accident, take a recorded statement from the policyholder, and request any documentation the policyholder can provide.
- Obtain a police accident report-insurers usually have a legal right to obtain police reports for accidents involving their policyholders.
- Collect other publicly available information about the accident, such as from news sources or social media.
From this information, the insurance adjuster will begin to formulate a picture of the potential types and amounts of claims the insurance company may receive in connection with the accident. The adjuster also begins to form an opinion about whether the policy covers those potential claims, and about potential reasons the company may have to deny the claim in part or in full.
The adjuster’s initial assessment helps the company decide how thoroughly and aggressively to investigate. If it appears obvious that the policy covers the damages and the claim seeks payment of a relatively small amount of money, the company may not investigate further. But if the adjuster doubts that the policy covers the claim, or if the amount at stake is large, the company may opt to dig deeper.
#3. Further Investigation
When a claim warrants further investigation, the adjuster will take additional steps to collect relevant information.
This might include:
- Contacting law enforcement officers involved in the accident response or investigation to obtain the information they can provide;
- Contacting an injured party through that party’s attorney (or directly if a lawyer doesn’t represent the party), seeking an interview with or information from that party;
- Conducting in-person investigation that may include, for example, visiting an accident scene, interviewing witnesses, or surveilling a claimant; and
- Investigating a claimant’s social media accounts.
The adjuster tries to uncover facts and evidence that reduce the insurance company’s obligation to pay a claim. The investigation is not neutral, however. The adjuster often has a powerful financial and career-related incentive to root-out information that will justify the insurance company denying part or all of the claim.
#4. Claim Determination, Negotiation, and Resolution
Having completed an investigation, the adjuster or someone else at the insurance company will issue a claim determination to the claimant. The determination typically spells out in writing the amount the insurance company is willing to pay on the claim and the reasons for refusing to pay any portion of it.
Claimants do not necessarily have to accept this as the final word on their injury claims. They can appeal claim determinations they disagree with.
Their personal injury attorneys can also often negotiate with the insurance company over the amount the insurance company will pay.
In most, but by no means all, personal injury cases, negotiation between an insurance company and the claimant’s personal injury attorney will result in a settlement, which is an agreement in which the insurance company agrees to pay an amount of money to the claimant in exchange for the claimant releasing the insurance company (and often, its policyholder) from further liability.
If insurers and claimants cannot settle, however, the claim can go to a judge or jury, usually through a lawsuit by the injured claimant against the at-fault policyholder.
Be Wary of Insurance Company Investigation Tactics
If you got hurt in an accident, any insurance company you may have a claim against-your own or someone else’s-may want to investigate. Depending on the size and strength of your claim, an insurance company may use a variety of tactics to dig into the details and find reasons not to pay you what they owe. Some of those tactics can feel aggressive and highly intrusive.
The best way to guard against high-pressure insurance investigation methods is to hire an experienced personal injury attorney as soon as you suffer an accidental injury and know that you may have an insurance claim to make.
By law, insurance companies usually cannot contact you directly if they know (or should know) that a lawyer represents you. Violating that rule can land insurance companies in hot water, and may entitle you to seek additional damages from them.
Regardless of whether you have an attorney on your side, however, always be on the lookout for these common insurance investigation tactics.
Pressuring You to Give a Recorded Statement
Insurance adjusters want nothing more than to get you on tape. Why? Because a recorded conversation between you and the adjuster constitutes admissible evidence in court. What you say to an adjuster in a recorded statement, in other words, they can and will use it against you.
And make no mistake, adjusters will do everything they can to shape what you say in a recorded interview. They’ll ask you leading, carefully worded questions designed to get you to give answers that harm your rights or undermine the value of your claim. If you say the wrong thing, it’s on tape and available for the insurance company to use as a reason to pay you less than you deserve.
If an insurance adjuster asks you to give a recorded statement, politely say no and refer the adjuster to your lawyer. Do not give in to pressure tactics. It’s unlikely that you have any obligation to give a statement to someone else’s insurance company. And even if you must give a statement to your own insurance company, it can and should happen on your terms and with your attorney’s involvement.
Demands for Medical Records
It’s usually reasonable for an insurance company to want to see some medical records detailing your accident-related injuries. But aggressive adjusters won’t stop there. They’ll also try to get you to hand over your past medical records dating back a decade or more, hoping to find some way to blame your injury on a pre-existing medical condition.
Do not hand over medical records to an adjuster, and do not sign any authorization for your providers to release medical records to the adjuster without first consulting with an experienced personal injury lawyer.
Investigating You Online
Insurance adjusters have learned that your online profile can sometimes contain valuable evidence to use against you. They’ll try hard to misrepresent your social media posts and other online activities to make you appear less injured and less traumatized than your injury claim suggests. They may even try to friend you or your close acquaintances online to get an insider’s look at what you’re up to.
Difficult as it may seem, the best practice while healing from an accident injury is to stay away from social media altogether. Even an innocent post can cost you dearly, so it’s just not worth the risk.
Let a Personal Injury Attorney Protect You in an Insurance Investigation
Insurance companies do not want to pay you what they owe and may engage in aggressive investigations to avoid their obligations to you. Protect yourself from their tactics by contacting an experienced personal injury attorney today.