Documenting and presenting your damages is part of making a personal injury claim. You’ve been injured, you’ve received treatment, you’ve collected medical records, and you’ve presented these to the insurance company. It’s easy for you to see the connection between your injuries and your treatment, so it’s natural to assume that the adjuster will see it the same way. Unfortunately, that is not always the case.
Disputed damages are damages in your personal injury claim that the insurance company is refusing to accept. Simply put, they are generally a medical cost or lost wage reimbursement that the insurance company denies. A dispute can occur over any damage presented in your claim, but it is very common for an adjuster to disagree on the necessity of medical treatment.
An adjuster may deny particular dates of service, individual charges or even entire medical facilities. A dispute over damages could come from any of the adjusters involved in your claim, including the at-fault liability insurance adjuster, the MedPay adjuster and even the uninsured/underinsured adjuster. If an insurance adjuster does initially deny certain medical treatment or is asking for additional supporting documentation, do not be alarmed. There are still steps to take to prove your damages.
Perhaps one of the most common reasons an adjuster will dispute your damages is that you have a prior medical history that could be the source of your injury, or they have reason to believe you have had a prior injury that could have led to your medical expenses.
For example, say you suffered a sports injury two years ago and you underwent treatment for your shoulder, including steroid injections and physical therapy. Your doctor was very impressed with your progress and you were released from treatment with no additional symptoms. A year later, you are involved in a motor vehicle accident and suffer a torn rotator cuff. When you present your expenses to the adjuster, your hospital records indicate you have a prior medical history of shoulder pain.
This is no surprise to you, right? You’re more than aware you had another injury. You know it’s not related. Your doctors know it’s not related. The insurance adjuster, however, is a different story. As soon as your adjuster sees that you have had treatment for your shoulder in the past, they will likely do one of two things: 1) deny the treatment altogether and/or 2) ask for 3-5 years of prior medical history.
The reason for this is to review your medical records for some sort of indication that the treatment you have received after the date of your accident is actually treatment related to a prior injury. If the adjuster can find any note that suggests your symptoms could be related to your prior injury, they have the justification they need to deny your claim for those related damages. In the above example, they will likely argue that your rotator cuff tear was caused by your prior injury. In this case, they may only offer to cover the expenses of your initial emergency room visit but not the resulting surgery.
Another example of disputed damages is when the adjuster deems part of your treatment as unnecessary or unreasonable. The adjuster could pick out individual charges that they feel are not necessary, or they could deny entire facilities. Using the same example above, imagine that you have undergone your surgery and are now in physical therapy to regain strength in your arm. The physical therapist recommends a treatment plan over the course of six months. You follow your doctor’s orders as planned and make a full recovery. However, the adjuster argues that the “typical recovery time” for your injury is only two months so they are not going to accept any of the treatment after the two-month mark.
On a smaller scale, the adjuster may say that a charge, such as hot and cold packs used by the therapist, were not necessary and will deny covering those charges. Another common denial of specific treatment often arises when a patient has returned for a follow-up appointment where imaging (such as an x-ray or MRI) is ordered to make sure everything is healing properly. The adjuster may argue that this additional imaging was not medically necessary.
If you are taken to the emergency room immediately after your accident, you are likely still experiencing an adrenaline rush, confusion and maybe even severe pain. Because of this, you tell the doctor that your neck and back are hurting, but you don’t mention your shoulder, either because it hasn’t really started hurting or because you are so distracted by everything going on that you don’t think to mention it. Two days later, your shoulder is so sore you can barely move it. Your doctor does some imaging over and diagnoses you with a rotator cuff tear.
Several months later, you submit all of these medical bills to the insurance company. In return, the adjuster denies all medical expenses related to your rotator cuff tear because you neglected to complain about shoulder pain in your initial visit.
Another common argument the adjuster may use to deny treatment is that you have had a significant gap in treatment or you did not properly follow the doctor’s orders. In our personal injury firm, this happens all too often when clients don’t schedule follow-up appointments like they should or do not follow the treatment plan that they arranged with their doctor. This is a big red flag in personal injury cases, and it’s understandable why an adjuster may use it as a reason to deny your claim.
Imagine that you go to your doctor complaining of severe shoulder pain and rate it a 9/10, and the doctor urges you to take a medication, schedule x-rays as soon as possible and follow-up with them next week. For whatever reason, you never fill your prescription, you don’t get your x-rays, and you don’t get back into your doctor’s office until three weeks later. Due to this gap in treatment, the insurance company will likely refuse to cover your treatment and any treatment past that date, citing that surely you were not that injured if you were able to go three weeks without doing anything your doctor ordered you to do.
With so many reasons an adjuster can try to deny your treatment, you may be wondering how to move forward with your claim. Don’t be afraid to stand your ground with an insurance adjuster. Remember, it’s their job to work against you, and they only have the information that you present to them. If an accident caused your injuries and expenses, be sure to provide all the documentation needed to prove the damages. In many cases, an adjuster will simply ask for additional documentation or clarification. In the worst-case scenario, an adjuster will flat out refuse to accept the treatment. If this happens, consider doing the following:
If the adjuster has asked for prior medical history or other proof showing your injuries or expenses are related to your motor vehicle accident, send additional documentation. Don’t be tempted to sign a release with the insurance company because they say it will make the process easier. Instead, gather additional records on your own. Sort through the records yourself, and find the dates of service or facilities that provide the proof the adjuster is asking for. From the above-referenced scenario, getting records from your prior shoulder injury showing that the doctor who treated you said you had made a full recovery and would have no additional symptoms is beneficial in showing that the new shoulder injury was not a result of the old one.
A causation letter is probably the most helpful piece of evidence, along with your medical records, to indicate to the adjuster that your injuries were a result of your accident. A causation letter should contain the following: 1) a detailed description of your injuries, 2) a breakdown of your recommended treatment plan, 3) the results of the treatment you received, 4) a comment about whether you have made a full recovery or may need additional treatment in the future, and most importantly, 5) a medical opinion as to what exactly caused your injuries and led to your treatment.
You might think that your medical records should provide the necessary information, but typically, medical records are not as clear-cut as a causation letter. Medical records contain details of each visit, including but not limited to a list of your symptoms, complaints made during your visit and recommended treatment moving forward. Unfortunately, medical records almost never state that all of the treatment is a direct result of the accident. A causation letter can establish just that.
Disputed damages are one of the trickiest aspects of a personal injury claim. While providing additional supporting documentation and getting a causation letter from your medical provider could overturn the initial dispute, there are times where an adjuster will still refuse to accept part or all of your treatment. When this happens, and before agreeing to just accept the adjuster’s stance, it may be time to speak to a legal professional. An experienced personal injury attorney will be familiar with North Carolina personal injury law and can help to advise you on how to proceed.