Do Insurance Companies Investigate Injury Claims?

Do Insurance Companies Investigate Injury Claims?

Short answer: Yes, insurance companies conduct extensive insurance investigations to find ways to deny coverage or avoid paying large claims.

If someone else’s negligence injures you, you have the legal right to request payment of your losses and legal damages. The first step usually involves filing a claim with the at-fault party’s insurance company. Once you file a claim, the adjuster opens an insurance investigation.

The adjuster’s primary goal is to decide whether you deserve any damage amount. Their second goal is to find evidence that they can use during negotiations to minimize the company's liability.

While the insurance company investigates your claim, you should consider hiring a lawyer. A skilled personal injury lawyer can perform an independent investigation to gather evidence in support of your claim and to maximize your final payment.

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What Do Insurance Investigators Look For?

Insurance companies investigate personal injury claims to avoid insurance fraud and find evidence that helps them deny claims or reduce settlement values.

Insurance Investigations Seek Evidence of Insurance Fraud and False Injury Claims

Insurance fraud costs American consumers several billion dollars every year. When insurance companies fail to catch fraud, it hurts their bottom line.

Common types of personal injury insurance fraud include:

• Soft insurance fraud involves inflating a claim. For example, a victim suffers slight whiplash in a car accident but claims severe neck injuries and mental anguish. While it is legal to request various types of damages, if a victim exaggerates their losses, they commit fraud.
• Hard insurance fraud involves creating an incident specifically to file a claim. For example, a person intentionally falls on a supermarket floor and claims they slipped on spilled milk. If they try to recover damages for extensive injuries based on an accident they created, it is fraud.

Insurance fraud can be a misdemeanor or a felony crime, depending on the state involved. Both charges come with significant penalties. Even if a criminal gets caught, the insurance company can suffer damages. To prevent insurance fraud from happening, companies conduct an investigation.

Insurance Investigations Also Look For Evidence of Exaggerated Personal Injury Claims to Help Them Minimize Payments

All insurance companies are for-profit businesses. When they have to pay large settlements, insurance companies lose money. Therefore, insurance investigators try to minimize payouts for personal injury claims.

Adjusters look for evidence to help them argue their case against the claimant during settlement negotiations or to a judge or jury in court.

For example, during an investigation, the adjuster could find:

• An eyewitness who is willing to testify that the insurance company's policyholder was not negligent. For example, if someone saw a property owner warn the victim about the dangers of broken stairs, but the person chose to climb them, the insurer may be relieved of responsibility.
• Evidence that more than one party was to blame for an incident. For example, in a vehicle crash, if the evidence shows that a mechanic failed to repair a driver’s brakes so the driver could not stop in time to avoid a collision, part of the blame may fall on the mechanic.
• Pre-existing medical conditions that could be the cause of the victims’ symptoms, as opposed to being caused by the policyholder's negligence

Sometimes, insurance adjusters will even lie to collect evidence that helps them minimize the payout. To ensure you do not fall into that trap, avoid sharing any information with the insurance company until you speak to a knowledgeable personal injury lawyer.

In general, insurance companies investigate claims to determine fault and minimize payments to the injured party. They will use all the information they collect during an investigation to deny a claim, negotiate a lower settlement, or win the case in court.

How Long Does an Insurance Company Have to Investigate a Claim?

Insurance companies usually prefer to settle claims as quickly as possible. In most cases, the company finishes its investigation in 30 days. However, some investigations can take months.

Factors that affect how long an insurance investigation may take include:

• The number of parties involved
• The complexity of the evidence
• Severity of injuries
• Presence or absence of witnesses
• The amount of financial losses at stake in the claim

When insurance companies are worried about making a large payment, they may extend the investigation. Adjusters could take extra time to dig up evidence to leverage in negotiations or try to wear the injury victim down over time, hoping they accept a lower settlement amount to pay their pressing expenses.

What Can I Expect During an Insurance Investigation?

Let's review the typical insurance investigation process and what you can expect to happen after you file an injury claim against someone else for harming you.

The Role of an Insurance Adjuster

When you file a personal injury claim with the at-fault party’s insurance company, that company assigns an insurance adjuster to that claim. Insurance adjusters are professionals who handle the claim from the moment of filing until its resolution. They investigate the case, conduct negotiations, and decide on a fair settlement amount.

The adjusters are the leading investigators of your injury case. They know the ins and outs of insurance, which helps them make effective decisions. However, adjusters are very busy people. They can have dozens of claims sitting on their desks awaiting action.

To process each claim, insurance adjusters take these five main steps:

1. Speaking to the Claimant

The adjuster calls the injured person quickly when they receive a claim. During this conversation, they learn about the incident, the extent of damages, and the evidence available in the claim.

Sometimes, the insurance adjuster may even call victims before they file a claim. This happens when their policyholder reports an incident, and the company decides to do some pre-claim research. During the conversation, the adjuster may try to catch injured people off guard or twist their words and pressure them into making damaging statements.

Remember that the law does not obligate you to speak to an adjuster. To protect your legal rights, you should hire a lawyer who can advise you about what to say or not say to the insurance company. If you decide to speak to an adjuster, be concise and stick to the facts. Do not agree to give a recorded statement during the first conversation.

2. Conducting a Visual Evaluation

An adjuster may travel to the accident scene in some cases. This can help them figure out what happened and allow them to evaluate property damage. The adjuster may decide against a visual evaluation if the claim amount is small. However, expensive claims warrant their maximum attention.

The adjuster may also ask to meet with the injured claimant. Speaking to victims in person can help them strong-arm injured people into making statements. Again, remember that you are not obligated to meet with an insurance adjuster. If they ask for a meeting, consider contacting a lawyer beforehand.

3. Speaking to Witnesses

The insurance adjuster looks for witnesses. In most cases, the police report includes witnesses’ contact details. The insurance company does not just talk to eyewitnesses to see if your story matches theirs. They record statements they can use against you.

4. Requesting Medical Records

The adjuster has to review your medical records to understand whether your claim is legitimate. You may have already sent some medical evidence when filing a claim. However, the adjuster may ask for more.

Adjusters pay close attention to medical information since it is usually crucial evidence in the claim. If they cannot find sufficient proof about the extent of your injuries, they can request more documentation.

You have the right to decide whether you want to share medical records. Refusing to share could cause the adjuster to claim a lack of evidence and deny the claim. However, you may also provide too much information or details the adjuster doesn't deserve to see. Before sending over your medical records, make sure to review them with an experienced personal injury lawyer. They can explain which documents you should share and which could hurt your case.

To gather your medical information, the adjuster may request the following:

Release Forms

Sometimes, an adjuster may ask you to sign a HIPAA (Health Insurance Portability and Accountability Act) release form. This release could give them access to all of your medical records. Your lawyer can tailor release forms to include only medical information related to the incident in question.

Never sign any information releases until you speak to a lawyer. Your entire medical history may contain evidence that adjusters could use as leverage to deny your claim or minimize your payment.

Medical Examinations

If the insurance adjuster doubts your injuries, they may ask you to submit to a medical examination. Usually, a doctor hired by insurance companies will perform the examination. These doctors are likely to say that your injuries are not severe or not related to the incident.

The good news is that you do not need to agree to such an examination. If your case goes to court, the judge may request a medical exam conducted by an independent professional. Speak to your lawyer to learn whether you need to submit to a medical exam and release the results to the insurance company.

5. Evaluating the Case

Once the insurance adjuster has all the necessary information, they can deny the claim, accept it, or offer a lower settlement amount than the amount requested by the claimant.

If the insurance adjuster denies your claim, you need to speak to a personal injury lawyer about what to do next. After reviewing your case, a lawyer can explain your options.

If you have a strong case, the insurance company may accept your claim but try to offer a low settlement. At that point, you can accept the settlement or negotiate for a higher amount.

Negotiating with an insurance company can be complex, time-consuming, and frustrating. Many people settle for an unfair amount simply because they cannot deal with the pressure and stress of working with the insurance company. Hiring a legal team that can handle negotiations on your behalf can ease this stress and frustration.

How to Respond to an Insurance Investigation

As the injured party, you are the key player when the insurance company conducts a personal injury claim investigation. While you want the insurance company to finish the inquiry quickly, being too helpful could work against you.

During the investigation:

• Avoid sharing unnecessary information. An insurance adjuster can use anything you say against you. Make sure you only say things that help your case. Better yet, delegate communications with the adjuster to your lawyer. Your lawyer's statements cannot be used against you during litigation.
• Do not talk to the insurance adjuster right after the accident. Tell them that you will give a statement later. Take the time you need to regroup, get medical attention, and call a lawyer.

Hiring a personal injury lawyer is the simplest way to respond to the investigation without hurting your chances of obtaining compensation.

Making the Insurance Investigation Work for You

While insurance adjusters look for fraud and errors during the investigation, they also gather legitimate evidence. Their investigation can support your case if you take the right approach to cooperation, data sharing, and negotiations.

To ensure that the investigation helps your case instead of hurting it, talk to an experienced personal injury lawyer as soon as possible. A lawyer knows how to manage investigations and help you receive the compensation you deserve.

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