Things Adjusters Say: We've approved $5,000 of treatment

This article is part of a series on insurance company's justifications for paying you less than you deserve. Whether through malice or ignorance insurance adjusters often refer to questionable logic and non-existent laws to award you as little money as possible. A personal injury attorney can ensure that you receive full compensation. The consultation is free.

I have a new client, Ms. Jones. Ms. Jones was badly injured in a car wreck, she missed work, she has medical bills in her mailbox, and she needs help making sure she is properly compensated for her damages. I accepted her case about two weeks ago. 

Today I got a phone call from the defendant's insurance company. We exchange hellos, verify contact information, and then the adjuster says the strangest thing:

Adjuster: I just want to let you know that we have completed our assessment of the case and have approved Ms. Jones for $5,000 of treatment. 
Attorney: Explain that to me.
Adjuster: Based on our investigation we have determined that $5,000 is a reasonable and customary amount of treatment for Ms. Jones' injuries. I don't want to see any medical bills above that number.
Attorney: How did you come to that conclusion?
Adjuster: We based our determination on the results of our investigation and the use of proprietary database software to determine the reasonable and customary amount of medical treatment.

Let's review what just happened. The insurance adjuster, without speaking to Ms. Jones, without speaking to her doctors, without even waiting for Ms. Jones to heal, has determined that Ms. Jones needs $5,000 of medical treatment, and not a penny over. When asked for a justification the adjuster talked about an "investigation" and "proprietary database software," in an attempt to sound authoritative. 

This $5,000 number is baseless. The adjuster made it up. It isn't admissible in court, it isn't relevant to any future negotiation, and it implies that the insurance company gets to ration medical treatment at will. 

This is a negotiation tactic called the "Authority Limit." The adjuster will throw out a number, say $5,000, and state early on that she cannot go any higher than that number. Later she will refer back to the $5,000 number, stating that even though she wants to pay out more money she isn't allowed to. She might even scold someone who goes over the $5,000 limit, saying something like, "I tried to help you by telling you how much we approved but you went over the limit." A lot of people, especially those not represented by an attorney, fall for this tactic. 

The only practical limit to the amount of money that is available is the policy limit. Don't let an adjuster use a simple negotiation tactic to convince you otherwise. The insurance company will use every trick they know to ensure you receive as little money as possible for the harms you have suffered. An attorney can ensure you receive full and fair compensation. The consultation is free.

Things Adjuster's Say: You didn't go to the ER

This article is part of a series on insurance company's justifications for paying you less than you deserve. Whether through malice or ignorance insurance adjusters often refer to questionable logic and non-existent laws to award you as little money as possible. A personal injury attorney can ensure that you receive full compensation. The consultation is free, and only one click away.

One of the most common ways an insurance adjuster will try to discredit your injuries is to claim that if you were really hurt your would have gone to the ER. This is a bad habit that carries over to the attorneys insurance companies hire to defend their clients in court. In my experience, this argument falls on deaf ears and can be turned around to show the court how absurd the defense is being.  

If he was hurt so badly, why didn’t he go to the ER?

I hear these words far more often than I should. Why did my client not go to the ER? It depends on the person, but here are some good reasons:

He did not think he needed to
He does not have health insurance
ER’s are very expensive
He had to take his children home
It was 10PM on a Sunday
He’s tough as nails and doesn’t like doctors

Whether or not you went to the ER is irrelevant.

Despite what the insurance industry wants you to believe, it doesn’t matter if you went to the ER or not. There is no requirement that in order to suffer a serious injury you have to ride in the back of an ambulance. Don’t let the insurance company belittle your injuries and disrespect you by saying otherwise.

Some people probably should have gone to the ER, but didn’t.

I have had clients with broken bones, broken vertebrae, torn ligaments, bleeding they could not stop on their own, bruises so bad they couldn’t open one eye, and head injuries that knocked them unconscious not go to the ER.  They probably should have gone to the ER, but for one reason or another they didn’t. But the bone is no less broken because the client did not go to the ER.  

In my experience, courts do not give any credit to this argument.

I had an insurance attorney ask my client why she didn’t go to the ER while she was testifying in court. She replied, “Because I wasn’t hurt enough to wait ten hours in the middle of the night for them to give me a bottle of pills and a bill for $5,000. I went home, went to bed, and saw my regular doctor the next day.” She said it in a smart, matter of fact way. The insurance company’s attorney looked like a fool and my client ended up being very happy with the judgement she received.

If I have a car wreck should I go to the ER no matter what?

According to the logic of the insurance industry, yes. According to common sense, no. You should seek whatever medical treatment you think you need. I always stress to my clients that they only have one body and should never compramise their health for the sake of their case.

Don't be taken advantage of.

An attorney can help ensure that you are not taken advantage of by unscrupulous insurance adjusters looking to line their employer's pockets at the expense of your injuries. Click here for a free consultation.

Things Adjusters Say: Health Insurance Already Paid Our Bill

This article is part of a series on insurance company's justifications for paying you less than you deserve. Click here for more ridiculous things insurance adjusters say to pay you less than you deserve. Whether through malice or ignorance insurance adjusters often refer to questionable logic and non-existent laws to award you as little money as possible. A personal injury attorney can ensure that you receive full compensation. The consultation is free. 

Adjusters say the strangest things: Health Insurance Paid the Medical Bills

The insurance company is trying to pay you as little money as possible, regardless of how injured you are or how much harm you have suffered. One of the insurance industry’s favorite ways to pay you less is to refuse to cover your medical expenses because you have health insurance. Not only is this argument illogical, it is also inadmissible as evidence in court. But that doesn’t stop insurance companies from trying to use it to short change you.

Let’s take a hypothetical client, Ms. Jones. Ms. Jones was injured in a car wreck. Her medical bills are $10,000, but her health insurance paid $9,500, leaving $500 which Ms. Jones paid out of pocket. The insurance company will argue that Ms. Jones should receive $500, since that is the amount of money she had to spend out of pocket.

Can the defendant pay me less because I have health insurance?

No. The legal doctrine preventing this is called the “Collateral Source Doctrine,” and it states that it is irrelevant whether or not the victim of a tort received compensation from a source other than the defendant. Or, as I find it easiest to explain to my clients: You do not get to benefit from insurance you did not pay for.

Let’s go back to Ms. Jones. Ms. Jones paid her health insurance premium every month, not the defendant. Why, then, should the defendant benefit from insurance he never paid for? He shouldn’t, and that is why Georgia has the collateral source doctrine.

Does the collateral source doctrine only apply to insurance?

The collateral source doctrine applies to any compensation the victim received from a source that is not the defendant or the defendant’s insurance company.

This includes any type of insurance such as medical payment coverage, short or long term disability, worker’s compensation, collision or comprehensive insurance on your car, and health insurance.

The collateral source doctrine also applies to acts of kindness. If Ms. Jones did not have health insurance and her church collected $10,000 to pay her medical bills the defendant could not use that fact to refuse to pay Ms. Jones’ medical bills. If Ms. Jones’ son fixed her car for free because he loves his mother the defendant could not then refuse to pay for the repair of Ms. Jones’ car.

The defendant, whose negligence caused the injury, does not get to benefit from insurance he did not pay for or from the kindness and generosity of others. No matter what the insurance industry says.

Isn’t that double dipping, getting paid for the same thing twice?

No, it is in the public good for people to be charitable and generous to one another, especially in a time of need. If a defendant could offset the harm he caused by relying on the generosity of others it may discourage charitable giving in the first place.  

As for insurance, Ms. Jones paid her insurance premium every month, not the defendant. Furthermore, depending upon the type of insurance she has she may have to pay higher rates in the future. Ms. Jones may also be legally obligated to pay back, in part or in full, the benefits her own insurance company paid out on her behalf. If Ms. Jones believes the lies the defendant’s insurance company tells her she could end up in what I call the subrogation trap.

What is the subrogation trap?

The subrogation trap is a situation in which a person fails to collect their full medical damages on the basis that their own insurance paid for those damages, but then becomes obligated to repay their own insurance company.

Back to Ms. Jones, she incurred $10,000 in medical expenses, her health insurance company paid $9,500 of those expenses, and she paid $500 out of pocket. The defendant’s insurance company told her they would only pay her $500 for her out of pocket costs and Ms. Jones accepted that amount. Unfortunately for Ms. Jones, her health insurance company has a right of subrogation, that is, a right to be reimbursed for medical expenses that they paid out.

The case has settled. Ms. Jones received $500 in medical damages, $3,000 in pain and suffering, and $1,000 in lost wages, for a total settlement of $4,500 (clearly, she did not have a lawyer). Unfortunately, her health insurance company has a right to be repaid $9,500 and is looking to Ms. Jones to pay that amount. Ms. Jones is now caught in the subrogation trap.

Do you want to guess what will happen when Ms. Jones calls the defendant’s insurance company? If they even pick up the phone they will make an empty apology, tell her there is nothing they can do, and offer a canned platitude. Not every insurance company has a right to subrogation, but the subrogation trap is a very real fear.

DON'T Be taken advantage of.

An attorney can help ensure that you are not taken advantage of by unscrupulous insurance adjusters looking to line their employer's pockets at the expense of your injuries. Click here for a free consultation.

Things Adjusters Say: We'll pocket your taxes

This article is part of a series on insurance company's justifications for paying you less than you deserve. Whether through malice or ignorance insurance adjusters often refer to questionable logic and non-existent laws to award you as little money as possible. A personal injury attorney can ensure that you receive full compensation. The consultation is free, and only one click away.

Most people who are involved in an automobile collision end up missing some amount of work. I’ve written before on the types of lost wages you are entitled to be compensated for. If the adjuster and I have agreed on the amount of wages you lost the adjuster will sometimes say something like this:

Attorney: So we agree, Ms. Jones will be paid for 17 hours of lost wages at her hourly rate of $20.00 an hour, $340.00 total.

Adjuster: Yes, 17 hours at $20.00 an hour. And we’ll go ahead and deduct 30% for taxes.

The adjuster’s logic is as follows. Ms. Jones, had she earned wages at her job, would have had to pay taxes on her wages. The amount of money Ms. Jones lost was thus not her pay before taxes, but the amount of pay she would have received after taxes. The adjuster may even argue that Ms. Jones would be committing tax fraud by not letting the insurance company deduct taxes from her compensation. I am telling you today that all of this is crap.

But Ms. Jones would have had to pay taxes on her wages!

Yes, she would have. But at what tax rate? Until Ms. Jones files her taxes for the year she doesn’t know her actual tax rate. The taxes taken out of your paycheck are an estimate, not a final rate. And her rate could be much higher or lower than 30%. It could be 10%. It could be 50%. It could be somewhere in between. The adjuster has no idea what tax rate Ms. Jones will pay on her wages and doesn’t get to speculate.

So does Ms. Jones have to pay taxes on her lost wages? Maybe. But the issue of tax rates and taxable income is between Ms. Jones and the IRS, not the insurance company.

But what’s the harm in letting the insurance company withhold money for taxes? Isn’t that what my employer does?

If you are like most people your employer withholds part of your paycheck to pay taxes. At the end of the year, when you file your taxes, you get a credit for the amount your employer paid to the government on your behalf. Every dollar your employer withholds as taxes is a dollar you do not have to pay in taxes at the end of the year. So what is the harm of letting the insurance company do the same thing? Because the insurance company is not withholding money to pay your taxes, they are pocketing the money for themselves. When the adjuster reduces your lost wage claim by 30% for taxes they are not sending the money to the government.

In short, the insurance company is charging you for taxes and then, instead of giving the money to the government, the insurance company is pocketing the money for themselves. Let that sink in for a second.

Don’t be taken advantage of.

The insurance company has an army of lawyers on their side working to pay you as little as possible. Adjusters will, out of ignorance or malice, use a variety of tactics to deny you compensation for the harms you have suffered. A knowledgeable personal injury attorney can stand up for you and make sure you receive fair compensation for your injuries. Call now for a free consultation