Disputed Damages
Documenting and presenting your damages is part of making a personal injury
claim. You’ve been injured, you’ve received treatment, you’ve
collected medical records, and you’ve presented these to the insurance
company. It’s easy for you to see the connection between your injuries
and your treatment, so it’s natural to assume that the adjuster
will see it the same way. Unfortunately, that is not always the case.
What are Disputed Damages?
Disputed damages are damages in your personal injury claim that the insurance
company is refusing to accept. Simply put, they are generally a medical
cost or lost wage reimbursement that the insurance company denies. A dispute
can occur over any
damage presented in your claim, but it is very common for an adjuster to disagree on the necessity of
medical treatment.
An adjuster may deny particular dates of service, individual charges, or
even entire medical facilities. A dispute over damages could come from
any of the adjusters involved in your claim, including the at-fault liability
insurance adjuster, the MedPay adjuster, and even the uninsured/underinsured
adjuster. If an insurance adjuster does initially deny certain medical
treatment or is asking for additional supporting documentation, do not
be alarmed. There are still steps to take to prove your damages.
Examples of Disputed Damages
Prior Medical History
Perhaps one of the most common reasons an adjuster will dispute your damages
is that you have a prior medical history that could be the source of your
injury, or they have reason to believe you have had a prior injury that
could have led to your medical expenses.
For example, say you suffered a sports injury two years ago and you underwent
treatment for your shoulder, including steroid injections and physical
therapy. Your doctor was very impressed with your progress and you were
released from treatment with no additional symptoms. A year later, you
are involved in a motor vehicle accident and suffer a torn rotator cuff.
When you present your expenses to the adjuster, your hospital records
indicate you have a prior medical history of shoulder pain.
This is no surprise to you, right? You’re more than aware you had
another injury. You know it’s not related. Your doctors know it’s
not related. The insurance adjuster, however, is a different story. As
soon as your adjuster sees that you have had treatment for your shoulder
in the past, they will likely do one of two things: 1) deny the treatment
altogether and/or 2) ask for 3-5 years of prior medical history.
The reason for this is to review your medical records for some sort of
indication that the treatment you have received after the date of your
accident is actually treatment related to a prior injury. If the adjuster
can find any note that suggests your symptoms could be related to your
prior injury, they have the justification they need to deny your claim
for those related damages. In the above example, they will likely argue
that your rotator cuff tear was caused by your prior injury. In this case,
they may only offer to cover the expenses of your initial emergency room
visit but not the resulting surgery.
Unnecessary/Unreasonable Treatment
Another example of disputed damages is when the adjuster deems part of
your treatment as unnecessary or unreasonable. The adjuster could pick
out individual charges that they feel are not necessary, or they could
deny entire facilities. Using the same example above, imagine that you
have undergone your surgery and are now in physical therapy to regain
strength in your arm. The physical therapist recommends a treatment plan
over the course of six months. You follow your doctor’s orders as
planned and make a full recovery. However, the adjuster argues that the
“typical recovery time” for your injury is only two months
so they are not going to accept any of the treatment after the two-month mark.
On a smaller scale, the adjuster may say that a charge, such as hot and
cold packs used by the therapist, was not necessary and will deny covering
those charges. Another common denial of specific treatment often arises
when a patient has returned for a follow-up appointment where imaging
(such as an x-ray or MRI) is ordered to make sure everything is healing
properly. The adjuster may argue that this additional imaging was not
medically necessary.
No Initial Complaint
If you are taken to the emergency room immediately after your accident,
you are likely still experiencing an adrenaline rush, confusion, and maybe
even severe pain. Because of this, you tell the doctor that your neck
and back are hurting, but you don’t mention your shoulder, either
because it hasn’t really started hurting or because you are so distracted
by everything going on that you don’t think to mention it. Two days
later, your shoulder is so sore you can barely move it. Your doctor does
some imaging over and diagnoses you with a rotator cuff tear.
Several months later, you submit all of these medical bills to the insurance
company. In return, the adjuster denies all medical expenses related to
your rotator cuff tear because you neglected to complain about shoulder
pain in your initial visit.
