Clients who read this 10-minute guide can get up to 10x better results.
Making a claim against someone else can be daunting, and we understand that you probably have many questions about the process. That's why we're here to provide you with some information on how insurance companies evaluate personal injury claims and determine how much to offer.
Insurance's processes, systems and people are trained to wear down the clients they insure. Their bottom line is to get you to accept the lowest amount of money possible. They determine how much they have to pay you using three criteria.
An insurance company first looks at which person was responsible for what in an injury claim. In Florida, we have something called comparative negligence. That means fault can be divided up between the parties as a percentage.
If two cars merge into the same lane at the same time, crash into each other, and are equally negligent, an insurance company may assign 50% fault to each person. If someone is walking down stairs holding an object in both of their hands and they trip and fall, but the stairs are not up to code, the insurance company may assign 25% fault to the person who is injured and 75% to the business owner, because the person who was injured may have been able to avoid the injury had they had both hands available to hold onto the railing.
What does that mean? So, if your case is worth $100,000 and they believe their insured is 75% at fault, then they will evaluate your case at $75,000. If they think half of it is your fault and half of the fault is of their insured, then it will be a $50,000 evaluation, and if they think it is 100% your fault, they will evaluate the case at $0. This can also be divided up even further if there are other parties involved. It is important to remember that liability issues may impact the value of your case.
In an injury claim, medical damages are what insurance companies look at next, and work from there to determine the value of your case. If you cannot properly document your injury claims, it becomes more difficult for the insurance company to pay for damages for things such as lost wages, future earning capacity, pain and suffering, loss of enjoyment of life, future medical treatment, and any of the other available damages you may have caused to you in your case. Here are a list of things an insurance company looks at when reviewing medical records and billing:
First date of medical treatment: If you waited many days or weeks to get medical treatment, the insurance company will lower the value of your claim. If you believe you are hurt, it is best to document your injuries as quickly as possible.
Consistent medical treatment: If you get injured and make a hospital visit, then do not follow up with a doctor for weeks or months after your first visit, the insurance company will devalue your claim. This also can occur after initial treatment, where an insurance company will assume your injury has resolved if you are not getting treatment for a long period of time. This is called a gap in treatment.
Documenting injuries: If your injury is not in a medical record, it does not exist to an insurance company. If you need to see a specialist to appropriately document your injury, such as a neurologist for head trauma, or a podiatrist for a foot injury, make efforts to see these doctors and tell them all about the issues you have had since the incident, so that it can be documented in your medical records.
Maximum Medical Improvement (MMI) and Future Medical Treatment: Typically, a client will begin with conservative medical treatment for several weeks or months. If that does not work, treaters will refer to specialists, such as surgeons, after they find that you have reached MMI with your treatment. We do not make suggestions on the type of medical treatment a client gets, but we would like the insurance company to know what available treatment options there are in a case so insurance can fairly evaluate. If you have a back injury that may require surgery in the future, the insurance company will only take that seriously if you have consulted with a surgeon and discussed options with that specialist. Again, you do not have to get a surgery, but if you have a something like a surgical opinion in your records, the insurance company is more likely to take your injury seriously.
Pre-existing injuries and causation: Insurance companies love to point out past injuries and accidents as the reason for your claims in your case. For example, if you have had prior complaints of neck and back pain, the insurance company will want to say that your neck and back pain pre-existed the new incident and will not pay for these injuries. Through your medical treatment, you will be able to document how these injuries are new and how the injuries were caused or worsened by the new incident.
Lost wages and future earning capacity: If you are missing work because of your accident, you are entitled to lost wages and potentially lost income in the future. The difficult part about lost wages is that the money in your case may take some time to get. Florida does not allow attorneys to lend clients money, so many of our clients must work through their pain as their case continues so that they can pay to keep a roof over their heads.
The existence of insurance coverage is crucial in your case. This is the best avenue to getting a recovery for your injuries. Below are explanations of different coverages in insurance claims.
Liability: When another person (third party) causes you injury, they may have insurance that covers damages caused to you. In an automobile case, this is also called bodily injury coverage. In Florida, this is not required, so many drivers have insurance but no bodily injury coverage. Liability coverage can also be seen in other places, such as homeowner policies, umbrella policies, and commercial policies. These policies are typically paid in one lump sum.
First-Party: This is coverage that you purchased that covers injuries caused to you by someone else. This is most commonly seen in automobile cases, where it is called Uninsured/Underinsured motorist (UM) coverage. This insurance only provides coverage if the coverage from the at-fault party is not enough. Your own insurance company will step into the shoes of the responsible person and defend the case as if they were the ones who caused your damages and will evaluate your claim as if they are the ones responsible. UM is not required in Florida.
Personal Injury Protection (PIP or No-Fault): All drivers/owners of cars are required to carry this insurance under Florida law. If you have PIP and you get diagnosed with an Emergency Medical Condition within 14 days, it will pay up to $10,000 in medical bills (80% of each bill) and lost wages (60% of lost wages) and pays regardless of whose fault it is. This will almost always come from your own auto insurance so long as you own a vehicle and have insurance on it. If you are injured in a car accident, you will use this insurance claim number from your own policy to help pay for initial medical treatment and recover for lost wages. You do not have to pay back PIP coverage out of any recovery you get. You may use this in addition to health insurance and other plans. Be mindful of the 14 day rule, because if you do not get diagnosed with an Emergency Medical Condition within 14 days, you may lose out on all of your available PIP coverage.
Medical Payments (MedPay): This can be seen in auto and other types of cases, such as premises liability. MedPay will pay a certain amount of money for medical treatment related to injuries, usually regardless of fault. This can come from the at-fault party or your own insurance, depending on what the policy says. MedPay usually must be paid back from any recovery but can be negotiated at the end of the case. If MedPay is available, provide the MedPay claim number to your treater as you would health insurance. MedPay is not available in all cases.
Health Insurance, Medicare, Medicaid, Tricare and beyond: You may get treatment under any available health care plan that you have as you would if there was not an insurance claim. Please provide your health insurance information to your medical treaters. Using health insurance and other plans does not mean free treatment. There will still be deductibles and co-pays. These plans almost always have a right of subrogation, which means that they can assert a lien on your case and you must pay them back out of any settlement for the treatment they paid for. These liens can often times be negotiated, depending on the policy.
Letters of Protection: What if you don’t have medical insurance? Do not worry. Some doctors will accept what is called a Letter of Protection, which is an agreement between you and the doctor that you will pay them back at the end of a case once you get a recovery. Ask your treater about this option and our firm can help assist with the paperwork.
Property Damage: In Florida, insured drivers are required to carry a minimum of $10,000 for property damage coverage. This can pay for repairs, for a total loss of a vehicle, to property damaged inside of the vehicle (like baby seats or sunglasses), and can help repay loans on vehicles that are financed. This does not include repayment for financed interest or the value of a replacement car, only the value of the vehicle involved in the crash. If your car is financed, you will want to determine if you have gap insurance so that you are not left paying for a car that you no longer drive. We allow our clients to negotiate and get the benefit of the full recovery from this. You may go through your own auto insurance and pay a deductible (which can be reimbursed at another date) or go through the other car’s insurance. Property damage can be settled by itself and will not impact your bodily injury claim.
What does this all mean? These are potential insurance policies you may tap into.
Our firm’s focus is on a) Liability and b) First-Party insurance policies.
These are the most difficult and time-consuming policies to recover from, which is why clients hire us. If there are neither of these policy types in your case, it is likely that we must close your file, as we can no longer assist in getting you a recovery, even if someone else is at fault. The reason is that it is very difficult to recover money from uninsured individuals. Florida is a safe-haven for people who owe money to others, where the Homestead Act and bankruptcy often shelters ones assets from recovery. There are exceptions to this, of course, but if we analyze your case and cannot find a clear path for recovery for you, we will let you know. We do our best to find this out quickly if that is the case.
In our nearly forty-years of practicing law, we have been involved in thousands of cases. In these cases, we've seen one thing that has separated the great results from the bad results. Below, you can find two identitical cases with a $90,000 difference.
Received treatment immediately at the hospital and began the process of healing
Followed up the next day with a specialist and began a course of treatment which helps treat pain and discomfort.
Consistently treated and documented injuries. Stays off of social media and avoids being in any posts that would allow adjusters to claim that they were not injured.
MRI revealed a herniation that requires future surgery, but pain is controlled with normal treatment. Followed up with neurologist to help with headaches and confusion, brain injury is documented and proven. Received a policy-limits $100,000 offer from the insurance company
Waits 10 days to get first treatment and 9 days to follow up.
Missed appointments and waited almost two weeks between visits. The pain from the injury is difficult, but they have never been one to visit the doctor. Eventually decides the constant doctor visits are a hassle and stops going.
Posts several image at a theme park, shares an image of them tossing a football with their kids and has a family member post a picture of them dancing at a wedding. They were in pain at each event, but the insurance company saw this and can now build a case that they might not be as injured as they appear.
Has an undiagnosed herniation that will require future surgery sooner because of lack of treatment. Has an undiagnosed brain injury which causes headaches and confusion and no proof of injury. Received a $10,000 offer from the insurance company due to the inability to prove any injury.
No questions are bad questions.
Do not sign any documents related to your case without our approval
Alert us of any changes in address or contact information
Do not speak with the insurance companies unless we approve
Share emails, calls and texts with information or updates in your cases
Do not file for bankruptcy during your case without speaking with us
Do not miss appointments without calling providers to re-schedule
Get treatment that you need
Do not get treatment that you do not want or do not feel comfortable with
Make yourself available if we reach out with requests for updates or information
Do not go long periods of time without necessary treatment
Some cases can be resolved in 90 days or less with a settlement, and other cases can take years going through a trial and appeals process. Each case is dependent on the variables listed above and how reasonable the insurance company is in the process.
It depends on so many factors, including the severity of the incident and your injuries, what your medical records and bills show, how much it has impacted your life, and how much insurance coverage is available. Since our firm receives a percentage of your case, we also would like you to get you as much money as you deserve in your case, but we are under a duty to act in your best interests.
Probably not. Although our firm is aggressive in our pursuit of trial, over 90% of cases settle. You also will have the opportunity along the way in your case to settle if you feel like trial is not for you.
To begin most cases, we start in the pre-litigation phase. This is where we gather your medical records and make a demand for money from the insurance company. If the insurance company pays, then your case is over. If the case cannot be negotiated, we will discuss with you about filing a Complaint with the court, and begin the litigation phase of the case, where we head towards trial. Along the way, there are opportunities to settle the case, including an event called a mediation. From beginning to end, a trial can start between 10 months to several years after a Complaint is filed, depending on the complexity of the case.
If you go to trial and lose, it is possible that you could owe the insurance company or defendant in the case attorneys fees and costs they spent defending the case. This is not a completely risk-free journey for you should the case go into a lawsuit. Along the way, we will continue to discuss with you the pros and cons of your case and the pros and cons of resolving versus going to trial. At the pre-litigation phase, there is no “losing,” only settling or making the decision to file a lawsuit.
Your legal team is at the ready to assist you.