How does the insurance claims process work?
Claims processes usually proceed in predictable steps. Previous to filing a claim, you will notify people who may be responsible for the accident, that you’ve been injured and plan on filing a claim for your injuries. This improves your chances of getting a speedy settlement and averts others from later stating that your claim unfairly surprised them.
Then, after you’ve taken the time to completely examine your claim by collecting evidence, determining who’s responsible for the incident, estimating what you consider your claim is worth, and preparing good arguments, you will write a formal demand letter and present it to the insurance company of the individual who you deem responsible for your injuries. (This may include your own insurance company — for instance, if you are covered by a no-fault automobile policy or need to make a claim for uninsured or underinsured motorist coverage.) Next, you will engage in informal discussions with the insurance company until you agree on a settlement you can live with.
The majority of insurance claims are that simple, however occasionally you may find yourself dealing with an inflexible or difficult claims adjuster. In this case, you must resort to more determined negotiation tactics — or perhaps consult an experienced personal injury lawyer. If all else fails, you may even have to take your case to court. Below you will find an attempt to answer what appear to be simple questions with a simple answers. Each issue raised below is based on complicated rules and statutes.
What are the guidelines I should follow when another person’s insurance company calls me to discuss my injuries?
Upon notifying others that you’ve been hurt in an accident and intend to file an injury claim, you may receive phone calls from one (or more) insurance companies that want to speak to you about what happened. During these initial discussions — which will most likely take place before you file your claim for compensation (called a “demand letter”) — you should abide by the following principles:
- Remain calm and polite
- Identify the person you’re speaking with, the company he or she represents and the person who is insured
- Give limited personal information (your name, address and phone number is sufficient)
- Do not give details about the accident or your injuries
- Avoid any push to settle your claim immediately
- Set limits on further phone contact, and
- Take notes about any important information you obtained during the phone call, as well as any information you gave to, or requests you made of the insurance adjuster.
Remembering these important rues will help you maintain your chances of receiving a good settlement for your injury claim.
How do I make a formal claim for compensation for my injuries?
After you decide which insurance company (or companies) should pay for your injuries, and you gather all the evidence you need to establish your claim, you must send the insurance company a demand letter. This letter is a critical element of your claim negotiation process, so it is essential that you write it carefully and well. In your demand letter, you set out your strongest arguments concerning:
- Why the insured person is legally responsible for your injuries
- What your injuries were and are
- What kind of medical treatment you’ve had and how much it cost
- What your income loss was
- What other damages you suffered, and
- If you have no-fault automobile insurance, why you qualify to make a claim against the insured person.
Your letter should conclude with a demand on the insurance company for a lump sum to settle your entire claim. This sum should be a good deal higher than what you’re actually willing to settle for; it simply gives you a good place from which to begin negotiations.
How do insurance companies decide how much they’ll pay to compensate someone for an injury?
While the final payment figure depends on negotiations with the injured person, insurance companies and lawyers do use a formula to calculate a range of compensation for an injury. In general, if you’ve been injured you can expect to be reimbursed for:
- Medical care
- Lost income
- Temporary and permanent pain and other physical discomfort, and
- Loss of family, social and educational experiences.
In calculating the range of compensation, a claims adjuster begins with the medical expenses. Then the intangibles — pain and other non-economic losses — are added in by multiplying the medical expenses by 1.5 to 2 times if the injuries are relatively minor, and up to 5 times if the injuries are more significant. The multiplier can go still higher — sometimes as much as 10 times medical expenses — if the injuries are particularly painful, serious or long-lasting. Finally, lost income is added to that amount.
You, too, can easily use this formula as the starting point for negotiations. Once the insurance adjuster knows that you understand the range of compensation for your injuries, negotiating a final settlement is usually quicker and easier.
Will my health insurance coverage or paid sick leave from work limit my compensation for an accident?
Whether you paid for medical care out of your own pocket or your health insurance covered it is none of a claims adjuster’s business. The same goes for whether your lost time at work was covered by sick leave or vacation pay. In fact, it is improper for an adjuster even to ask about such payments. You paid for your health insurance and earned your sick leave or vacation pay; now the insurance for the person who caused the accident has to pay.
Your own health insurance, however, may require that, out of your settlement, you reimburse it for some or all of the amounts it has paid to treat your injuries.
How long will my case take?
The court process can take months or years, depending on the jurisdiction. Wherever the suit is filed, your attorney should know the best ways to get your case set for trial as soon as possible. While many cases and individual defendants settle before trial, your lawyer should always be prepared to go to trial.
The last thing you want to do is resolve your case while you are still in the healing process or if you do not have a good understanding on what your future medical condition will be. Every plaintiff’s lawyer’s fear is to allow the client to sign a release and then find out a short period of time thereafter that the client needs future surgery or still has massive medical bills to pay. With that being said, typically the average auto case/premises liability case or any other type of general negligence case can be resolved within six to twelve months after you have retained an experienced personal injury attorney. Naturally, that time range is subject to fluctuation, depending upon the facts of each case.
Do I file a claim?
Our civil justice system was established so that the citizens of this country would be held responsible for their own actions or their own failure to act when appropriate. Rather than expecting the police or other government officials to invade every aspect of our lives, individuals or businesses can be sued and be forced to answer for their wrongful behavior.
How do I file a lawsuit?
To file a lawsuit you should know that the one filing the lawsuit is called the Plaintiff and the one being sued is the Defendant. Both the Plaintiff and the Defendant are a “party” to the lawsuit.
The Plaintiff can be a person at least 18 years old, an adult guardian or parent of a minor, a business partnership, a company or a corporation.
The Defendant can be any person, business or corporation.
If the Plaintiff or the Defendant is a corporation, the corporation may be required by law to hire an attorney.
How long do I have to file a claim?
In any state, there is a window of opportunity for filing a claim or a lawsuit. Simply stated, you can’t wait too long after an accident to file, or you’ll lose the right to be compensated. The legal term for the rule prohibiting you from waiting beyond a specified time period is a “statute of limitation.” The time period during which you must file a lawsuit changes based on the type of claim you are making.
There are basically five areas in the treatment of any claim by insurance companies:
- Verify whether the policy was active at the date of loss and if the claim against the insured falls within the terms of coverage.
- Assess the range and extent of the claimant’s allegations.
- Determine on the legality and credibility of the claim and claimant.
- Determine how much it will cost to resolve a third party claim and/or how much it will cost to defend a third party claim in a trial.
- Decide if they will settle a claim outright or go to trial.
If you are the claimant, it is imperative that you understand how the players within the insurance system play in order to collect settlement and payment for damages. Following are five (5) issues to consider and understand in dealing with the insurance adjuster:
- Who’s Who within the insurance system
- How insurance adjustors defend themselves
- How to avoid “bad faith” traps and unfair settlement techniques
- How to prevail within the system
Generally, there is a range of techniques that an adjuster might utilize in dealing with you as a claimant:
- Low-balling settlement offers
- Excessive delays
While medical expenses and lost wages may be relatively easy to calculate, the specific formula to calculate them. The amount of money to which an injured person is entitled for the various types of damages depends upon many things, including the severity of the initial injury, how well the person is recovering, and how well the person is expected to recover in the future.
How much can I expect?
Although this is a very sensible question, it is also virtually impossible to answer until all of the details and conditions of your case are known. While it may be possible for a lawyer to make an educated guess as to a very wide range of the probable worth of your case before all facts and circumstances are known, it is not realistic to expect anything more definite than that. You must also keep in mind that any initial opinion is subject to change, perhaps substantial change, as more facts become known.
Even after most or all facts are known, the most a lawyer can do is give you an educated guess based on his or her experience as to what a jury might award you if the case goes to trial. Starting from there and then factoring in such things as the likelihood that a jury might award nothing, the lawyer can tell you what amount is reasonable for you to accept in settlement. The law allows a person injured by the wrongdoing of another person or company to collect the following types of compensation:
- Past and Future Medical Bills
- Past and Future Lost Wages or Income
- Pain and Suffering
- Loss of a Normal Life (for example, disability)
- Disfigurement (for example, scarring or loss of a limb)
- Aggravation of a Pre-Existing Condition (for example, if a problem you had before the accident is made worse by the accident)
- Wrongful Death (certain family members are entitled to be compensated when a relative is killed)
- Survival Damages (the estate of a person who ends up dying from an injury may be entitled to payment for the conscious pain and suffering experienced by the deceased victim prior to death)
While medical expenses and lost wages may be relatively easy to calculate, the other damages listed above are more difficult to determine because there is no easy way to calculate the amount of one’s “pain and suffering” or the value on such things as “physical disfigurement.” These types of damages are typically referred to as “intangible damages” due to the problems associated with calculating their amount. These damages are decided on a case-by-case basis.
What are my Legal rights in a fatality case?
Wrongful Death is a legal term that refers to situations where a person dies due to the negligence of another. The goal of a wrongful death case is to compensate the survivors and beneficiaries for their loss.
The following types of damages are considered in a wrongful death case:
- Sorrow, mental anguish which includes loss of companionship, comfort and guidance;
- The expected loss in income of the person who died;
- The expected loss of services, protection, care, and/or assistance which the person who died provided to the survivors/beneficiaries;
- Expenses for the care, treatment, and hospitalization of the person who died related to the injury
When victims die in fatal accidents, the survivors are often unsure how to handle the aftermath of the tragedy. When fatal accidents are caused by negligence on behalf of a driver, company, employer, contractor, manufacturer or the like, the decedent’s family may have the legal right to seek compensation for the losses suffered in fatal accident.