Why an Insurer Might “Exclude” Visits in a North Carolina Injury Claim
Most personal injury claims come down to a simple question: what harm did the accident cause, and what did it reasonably take to treat it? Insurers often review records line-by-line and may decide some treatment is not connected to the accident (or not reasonably necessary), even if you and your providers believe it was.
Common reasons insurers give include:
- They dispute causation: They argue the visit was for a condition not caused by the accident (for example, symptoms that started much later, or a body part they say was not injured in the crash).
- They dispute reasonableness/necessity: They argue the frequency or duration of care was more than what the injury typically requires, especially in soft-tissue cases.
- They point to gaps or changes in care: A long break in treatment, switching providers, or changing complaints can give them an argument that later visits were for something else.
- They point to prior similar symptoms: If records show earlier neck/back/hip complaints, they may claim the accident did not cause the condition (or only temporarily aggravated it).
What You Must Prove to Recover Those Medical Expenses
In North Carolina, to recover medical expenses as part of an injury claim, the treatment generally needs to be tied to the accident and supported as reasonable and necessary for the injuries caused by the incident. If the insurer disputes certain visits, the issue is usually proof—not whether the insurer is “allowed” to disagree.
In plain English, the stronger your file is on these points, the harder it is for an insurer to justify excluding visits:
- Clear timeline: Symptoms and treatment start soon after the accident and progress in a way that makes sense.
- Consistent complaints: The same body areas and symptoms show up across visits (with understandable changes as you improve or flare).
- Provider explanation: Notes (or a separate narrative) explain why the care was needed, what objective findings existed, and how the provider connected it to the accident.
- Reasonable course of care: The frequency and duration of visits are explained in the records (for example, documented functional limits, response to care, and discharge plan).
What Usually Helps When the Insurer Says Visits Were “Unrelated”
When an insurer excludes visits, the goal is to close the documentation gap that created the dispute. In many cases, that means tightening the medical story rather than arguing in circles with the adjuster.
- Make sure the records match the injury story: If the accident involved head/neck/hip/leg complaints, the notes should reflect that consistently.
- Ask for a causation-focused provider statement (when appropriate): A treating provider can sometimes clarify, in plain terms, whether the accident caused or aggravated the condition, and why the specific course of care made sense.
- Address treatment gaps directly: If there was a break in care, the file should explain why (work constraints, symptom changes, scheduling issues) rather than leaving the insurer to guess.
- Separate unrelated care: If some visits truly addressed a different condition, separating those charges can keep the dispute from spilling over into the whole claim.
A North Carolina Pitfall: Fault Arguments Can Affect Everything
Even when the main dispute is “which visits count,” insurers often also look for fault defenses. North Carolina follows contributory negligence rules in many negligence cases, meaning an insurer may argue the injured person contributed to the crash and should recover nothing. If that issue is raised, it can affect how aggressively the insurer disputes treatment and damages.
How This Applies
Apply to these facts: Here, the insurer valued the claim using treatment records that include multiple provider visits and chiropractic care for leg/hip, abdomen, head, and neck complaints. If the insurer says some visits were “unrelated,” the most likely pressure points are (1) whether the records clearly connect each body area to the accident, and (2) whether the notes explain why the frequency and duration of care were medically necessary. A focused provider clarification and a clean timeline summary often help narrow what the insurer is disputing.
What the Statutes Say (Optional)
- N.C. Gen. Stat. § 1-52 – lists the three-year limitations period that commonly applies to personal injury actions in North Carolina.
- N.C. Gen. Stat. § 1-139 – places the burden of proof on the party asserting contributory negligence as a defense.
Conclusion
An insurer can exclude doctor visits from its evaluation if it believes the visits were not caused by the accident or were not reasonably necessary. That is a common negotiation point in North Carolina injury claims, especially when records leave room for questions about timing, gaps in care, or the reason for ongoing visits. The most helpful next step is usually to organize a clear treatment timeline and work with a licensed North Carolina attorney to identify what documentation would best connect the disputed visits to the accident.
