What Defenses Do Insurance Companies Use To Avoid Paying Out On Personal Injury Claims?
Insurance companies might argue that the claimant should be held liable for the accident, even if the circumstances seem to clearly indicate that the defendant was at fault. For example, an insurance company might claim that the only reason the defendant rear-ended the claimant was because the claimant made a sudden stop. Alternatively, they might argue that if the claimant was not wearing a seatbelt at the time of the accident, then the defendant should not be held entirely liable for the damages. They might also try to pin liability on a third party. Once a certain percentage of fault has been attributed to the claimant, the value of their claim can be reduced by that amount.
Another common argument made by insurance companies is that the claimant’s injuries were preexisting. For example, if an MRI performed after the accident shows herniations, the insurance company will commonly claim that those herniations were caused by a prior event that was completely unrelated to the auto accident. The insurance company will then try to make this or a similar argument even if the medical records and imaging do not indicate a preexisting injury. The insurance company will argue that since the injuries existed prior to the accident, the defendant should not be held liable for them.
Another defense is to argue that the injuries are not a result of the accident, but a result of the natural aging process or past life experiences that led to degeneration. The more degeneration the claimant has, the more the insurance company will try to use that to argue that their current pain and suffering is not associated with the auto accident. As a result, they will try to reduce the payout or deny the claim.
Another common element of the defenses used by insurance companies is that there is no permanent injury. In Florida, if a claimant cannot prove that they have a permanent injury, then they are not entitled to compensation for non-economic damages (i.e. pain and suffering). Insurance companies will use this argument to pay only the economic damages, usually meaning the medical bills to date. On top of that, the insurance company will then argue that the medical bills are inflated, and therefore they will offer to pay only a small fraction of them.
Depending on the injuries, an injured claimant may be recommended for surgery. In order to be compensated by the insurance company for the cost and pain and suffering of going thought the surgery, the insurance company will typically take the position that the claimant will have to actually go forward with the surgery before closing the claim. However, this is not how the law works. Florida law currently provides that all future medical expenses that are “reasonably certain” to be incurred are awardable. In many cases, the claimant is recommended for surgery but unsure about actually having the surgery because surgery is a very big deal and comes with many risks, including death. In these situations, the insurance company will take the position that the surgery is not necessary and will not offer to compensate the claimant for the cost of that surgery. What claimants need to understand is that whether it is a pre-litigation claim or a claim in a lawsuit, there is only one chance to receive compensation; once the claim or lawsuit is over, they will not get any additional money. Unfortunately, you cannot come back 3 years later when you actually go under the knife and request the insurance company pay for it then and that is why it is extremely important to be compensated for your future medical expenses during your claim even if you have not actually undergone the procedure yet. Insurance companies will argue that if the claimant has chosen not to immediately undergo surgery, then they are not really that injured, and they do not really need the surgery. This, of course, could not be further from the truth.
Insurance companies will also argue that the claimant should not be entitled to any future medical expenses because they will have health insurance that should cover it. This is also not accurate, because the claimant could lose their health insurance, the laws could change with regard to preexisting injuries, etc. Just because the claimant has health insurance at a particular time, does not mean they will have that benefit for life.
To drive down the value of a claim, insurance companies also commonly point to gaps in treatment as evidence of the claimant not being very injured. A claimant could reasonably miss four or six weeks of treatment due to a death in the family, but the insurance company would still argue that the gap in treatment indicates a lack of injury, or is evidence that the claimant is feeling better. If the insurance company can argue that the claimant is feeling better, then they will argue that it is not a permanent injury, and thereby avoid paying non-economic damages. These are all factors used by the insurance industry to try and drive down the value of claims.
In some cases, the insurance company will dispute that there is coverage at all. They may take the position that the claimant was not completely truthful on their application (even for a simple mistake such as writing the wrong zip code) and because of that they are going to deny the claim on that basis. There are many other defenses, but these are some of the most common we are confronted with on a daily basis.
For more information on Defenses Used By Insurance To Avoid Paying Claims, an initial consultation is your next best step. Get the information and legal answers you are seeking by calling (727) 490-8712 today.
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