The challenges of working with Insurance Adjusters… and what you, the Physician, can do about it.

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Automobile collisions happen, and anyone can be a victim. When injuries follow, doctors are the first to be asked for help, but more, doctors can be the most important element later, when their injured patient seeks reasonable compensation for both the medical bill, and for the other harms caused by the collision.

This second role a doctor often unknowingly happens upon the review of the medical record, notes and reports that follow the treatment and care of the injured patient. When notes are poor, incomplete, illegible, and when they fail to causally “connect” the collision the injuries, auto insurance claims adjusters have a proverbial field day. The doctor’s records, when poor, will serve to victimize the injured party financially, because the claims adjuster will often deny, or partially deny claims. This hurts both the patient and the doctor, who might otherwise be looking for the patient to obtain compensation to pay the bill.

In fairness, there are some people who are fraudulent, and others who will exaggerate injuries and losses to take advantage of insurers. Insurers should investigate, and they should pay what they owe. Unfortunately, in too many instances when problems arise, adjusters go overboard, or worse, claiming they are being fair. The reality is they are watching the company’s bottom line.

Insurance was once something we could rely upon. In today’s world of automobile collision claims, it is too often quite the opposite. Insurance companies now routinely “fight’” claims rather than fairly investigate, and the adjusters justify the delays, denials and reductions with the flimsiest of reasons. Sometimes, what is said is unfathomable.

In the world of automobile insurance, we buy “uninsured motorist” and “underinsured motorist” protections. These protections provide a safety net if the at fault driver does not have any, or not enough insurance, or flees the scene and remains unidentified. We pay premiums for these protections, and we rely on 
“our company” in those situations.

Yet, even when dealing with our own insurer, major aggravation can follow.

Long ago, if a disaster struck, we knew insurance was there to protect us. We felt secure. We felt safe.

Insurance was our safety net. For most of us, without insurance, there is a constant threat of financial ruin if just one unaffordable loss occurs; even one moderate disaster could be our complete financial end. A lifetime of savings could otherwise be wiped out by a single loss. How could we pay all of the medical bills and recover from income losses? Insurance was critical.

Insurance was also a profession. The agent was similar to our banker, our priest or our doctor or attorney. Insurers were not just about making money; our needs were first, above theirs.

All of this changed in the early 1990’s. Insurers went from trusted advisors to profit centers. Profits that boggle the mind. Profits so outrageous that honestly, it almost seems criminal.

Historically, insurers subscribed to two principles that guided their work. The first, the Fiduciary Principle, required prompt payment of claims. We relied upon this principle and still do today; we somehow intuitively feel it exists, or that it should. When we have a significant loss such as a car accident, we rely on the insurance to get us back to normal, to make our “down time” as short as possible. We count on getting our car repaired so we can get to work, to take the children to day-care or to school, or to run household errands. We need our car to go to the doctor for medical appointments. We need our insurance to do what we paid them to do, to pay for the car repair and for the medical appointments, because we do not have the money for those things. We rely on insurance.

The second principle that guided insurers was the Indemnity Principle. It means fair payment, and full payment. It means if it costs $5,000.00 to fix your car’s rear damage, they pay $5,000.00, not $4,100.00 because there was some rust on 2 inches of the bumper. The objective is to restore you to the same financial position after the loss that you were in prior to the loss.

Delaying claims processing is in direct contrast to the “old” insurance Fiduciary Principle of prompt payment. Today’s insurance adjusters rarely answer the telephone and despite leaving multiple messages on their voicemail, they rarely return calls promptly. So we have to make do on our own.

Note that while a claim is being denied, the insurer is holding the money, realizing profits on the interest the money is earning in their bank. Every penny paid to a claimant is a minus on the insurer’s balance sheet.

Here are comments this author has collected from attorneys in Maryland and Virginia, made to them by adjusters during the claims negotiations process:

Your client is fat, she probably had lots of problems and this accident didn’t cause any of them.

Your client didn’t need surgery. Some people just want to get cut. He intentionally just wanted to have an unnecessary surgery.

A motorist made a tight left turn and struck a pedestrian. The pedestrian suffered a brain injury, cuts and bruises on his legs and a fractured foot. The adjuster said the pedestrian must have passed out and fallen against the back of the truck causing his own injuries.
A drunk driver struck a vehicle, causing an eight-year old child in the car to hit his face and lose four teeth. The adjuster said kids lose teeth all of the time, it’s not a big deal.

A man’s wife was killed in a car accident. After two years he returned to dating. Unbelievably, his girlfriend was then killed while riding as a passenger in his car. The insurance adjuster said that the man’s anguish after the death of his wife was so high that it couldn’t get much worse.

A woman made a claim against her boyfriend, who caused an automobile accident injuring her, because she needed her medical bills paid and her wages reimbursed. The adjuster asked: didn’t the woman truly love her boyfriend, and why is she suing him?

An adjuster refused to pay a man for the wages he lost when he had take time from his job to attend doctor’s appointments and therapy. The adjuster offered that the man should have gone during his lunch hour. (Note that it is mostly impossible to travel back and forth, and spend any reasonable time for the administration of therapy in an hour).

In reviewing medical records for a woman who decades prior had a sexually transmitted disease, a claims adjuster made a condescending comment, as if the adjuster, a male, was at a frat party. The woman’s attorney pointed out that her accident injuries were not a result of a disease.

An attorney offered the following observation:

I have also come to believe that this is a good field to seek employment for misanthropes who are not bothered by efforts to belittle and bring down fellow human beings.  For those who have never outgrown the mindset of a mean child who pulls the wings off of bugs while they are still alive, this can be a field where they can earn a paycheck for having a mentality like that.

I tell my clients that the reason I have a job is because the insurance companies do not do what they should.

Many insurance adjusters should be ashamed of themselves. Fiduciary and Indemnity principles are mostly gone in today’s insurance claims world.

Doctors: write complete and thorough reports, and state affirmatively that the injuries were caused by the collision. Don’t give claims adjusters more ammunition with which to victimize your patients further.

About The Author

Paul A. Samakow, Esq.Speaker and Consultant
The Business Answer

Paul A. Samakow is a business consultant for orthopedists across the country, and an trial attorney in Maryland and Virginia since 1980.  He represents injury victims and routinely battles insurance companies and big businesses that will not accept full responsibility for the harms and losses they cause.

His book “The 8 Critical Things Your Auto Accident Attorney Won’t Tell You” can be instantly downloaded, for free, on his website: http://www.samakowlaw.com/book.