How Do Insurance Adjusters Really Evaluate Injury Claims?

How Do Insurance Adjusters Really Evaluate Injury Claims?

Before devoting my practice to helping injured victims, I represented an insurance company early in my legal career. I've seen firsthand how injury claims are evaluated and negotiated. Many people believe an insurance adjuster simply adds up the medical bills and makes an offer. In reality, the process is far more complex.

Insurance adjusters are trained to evaluate risk. Their job is to determine not only what your claim is worth, but also how likely it is that you and your attorney could prove your case if it were presented to a jury.

Some of the most important factors an adjuster considers include:

Liability: Who caused the accident? Is fault clear, or is there evidence that the injured person may share some responsibility?
Medical Evidence: Do the medical records consistently document the injuries? Are the complaints supported by diagnostic imaging, physician findings, and the course of treatment?
Credibility: Are the statements made to medical providers, the insurance company, and during the claim process consistent? Any inconsistencies can significantly affect the value of a claim.
Nature and Severity of the Injuries: Serious injuries requiring surgery, injections, prolonged physical therapy, or permanent impairment are evaluated differently than minor soft tissue injuries.
Future Damages: Adjusters evaluate whether future medical care, future pain and suffering, lost earning capacity, or disability.

 

The following California jury instruction is worth noting:

 

CACI No. 3905A provides the Judicial Council’s standard instruction for instructing juries on physical pain, mental suffering, and emotional distress — the core noneconomic damages in personal injury cases. 

• There is   no fixed standard   for determining the value of noneconomic damages.

• The jury must use   its judgment   to decide a   reasonable amount   based on the evidence and common sense  

• For   future   pain or suffering, the plaintiff must prove they are   reasonably certain   to suffer that harm.

• The jury should determine the amount in   current dollars at the time of judgment   to compensate for future harm.

• Do not further reduce   the award to present cash value — that reduction applies only to economic damages (see CACI No. 3904A and 3904B)

• The award should already reflect the idea of “today’s dollars for tomorrow’s loss” (Salgado v. County of Los Angeles (1998) 19 Cal. 4th 629, 80 Cal. Rptr. 2d 46, 967 P.2d 585

• If both future economic and noneconomic damages are claimed, include the last sentence about combining them  

• In   survival actions   (Code Civ. Proc., § 377.34), the instruction can be adapted to cover the decedent’s pre-death pain, suffering, or disfigurement