Posted On May 27, 2014 Personal Injury

Foul Play: Insurance Adjuster Sees Medical Records, But Just Doesn’t Believe Them

You pay your auto insurance premiums in exchange for a promise of coverage. In states with no-fault laws involving accidents, a crucial part of that coverage is personal injury protection, or PIP, the portion of coverage which pays your medical bills if you are hurt. But imagine that you get hurt and that the insurance company to whom you’ve paid thousands of dollars suddenly decides that it knows better than your doctors what tests and treatments you need.

Sometimes, the rationales behind such decisions are as simple as they are absurd. The injury could potentially have another cause other than an automobile accident, even if there is no evidence to support such a theory. If so, the insurance company wouldn’t have to pay for your treatment.

You don’t have to be a lawyer to see the flaws in this line of thinking or to know that you’d need evidence to back up this argument. But why should insurance adjusters let a little thing like logic get in the way of their speculations?

Why Bother with the Facts of the Claim?

A few months ago, a young woman was hurt in a motor vehicle accident. She went to the emergency room, where doctors examined her injured shoulder and ordered X-rays. Given this seemingly obvious chain of events, you might expect that the insurance company wouldn’t be all that surprised when, later in the course of treatment, doctors recommended an MRI of the same shoulder. Yet much to the frustration of the teenaged victim and her mother, their own insurance company refused to “pre-certify” the test.

By refusing to cover the test, the insurance company held up the injured young woman’s treatment for several days. Photo Credit: Pixabay (public domain).

The mother of the young accident victim called the adjuster to argue for pre-certification. After all, not one but two separate doctors had ordered this test. The need for evaluating the shoulder injury at this stage of treatment was clear. But to an insurance adjuster, no circumstance is quite clear enough. As he was speaking with the victim’s mother, the adjuster had the victim’s entire medical history – from birth until this accident and all of the treatment that resulted from it – in front of him.

The victim’s mother demanded to know why the insurance company was denying treatment to its own policyholder by refusing to pre-certify the MRI.

“How do we know the injury is from the accident and not a softball injury?” the adjuster replied.

The More You Think About this Excuse, the Less Sense It Makes

To the insurance company, the mere act of having previously played softball meant that the accident victim shouldn’t get medical benefits like the coverage of doctor-recommended tests. Consider that for a second. A company that serves no other purpose besides investigating and paying claims decided, on the basis of no evidence, that past pitching experience was sufficient proof of its bizarre hypothesis that the injury didn’t result from the car accident, even though the victim never complained of the injury until after the collision.

If former softball players can be excluded from receiving medical benefits through their insurance policies, they shouldn’t these individuals be excused from the legal obligation to purchase insurance, too? And why stop at softball – what about football players, runners, and anyone who ever belonged to a fitness center or had to take a gym class in high school? After all, couldn’t all of these activities cause injuries that sufferers might later blame on car accidents, at least according to the insurance company’s argument?

You don’t have to blow up the argument to ridiculous proportions to see how wrong it is. The adjuster in this case literally had the victim’s entire medical history in front of him. He could see that nothing in the victim’s medical records conveyed any past shoulder complaints of any kind, softball-related or otherwise. He also knew that the victim went to the emergency room following the accident and had shoulder X-rays taken at that time. Yet he had committed to this assumption that something other than the accident had caused this injury.

What this insurance adjuster didn’t know was that the mother of this victim worked here, at our personal injury law firm, as a litigation paralegal. He soon found out who he was dealing with, and just as soon, the insurance company was pushing through all pre-certification requests. What had previously taken several days – not to mention arguments – now took just a few hours.

How Widespread the Problem Really Is

Even though we hear of stories where insurance adjusters give claimants – including their own policyholders – a hard time, we all want to believe that it won’t happen to us. In some way, perhaps everyone just wants to think that an adjuster wouldn’t really deny a legitimate claim. Individually, we know that any claim we personally make is legitimate. Deep down, we expect our claims to be honored, the medical bills to be paid, and those tests and treatments to be pre-certified.

But the insurance industry doesn’t work that way, at least not anymore. Instead of treating claims as legitimate until there appears a reason to think otherwise, these corporations now treat every claim as something they can get out of paying. If a claim isn’t fraudulent, perhaps the company can say that the event isn’t covered, or that someone else is liable, or that the injuries didn’t result from the accident. The list of excuses goes on and on. No one is immune to poor treatment at the hands of a defensive insurance company, even those of us who work in personal injury law. The only way to prevent insurers from taking advantage of you is to know their tricks, know the law, and refuse to back down – or have someone on your side that does.