INJURY CLAIM FAQ

When an accident of any sort happens, one or more insurance policies may provide coverage. The person who caused the accident might have liability coverage, and the victim might have Personal Injury Protection (PIP), Premises medical, Health insurance, or might be qualified for government provided health care or other assistance. All of these sources might be used to pay the losses, partially or entirely, depending on the type of insurance.

Insurance covers the named insured for all the perils mentioned in the policy, except for those that are excluded. Other people might also be covered. For example, the standard homeowner’s policy covers all residents of the household who are related to the named insured, or are dependents under the age of 21. Domestic animals belonging to or in the care, custody and control of the named insured and all dependent under the age of 21 are normally covered.

Liability insurance covers the person or company that is responsible/ liable for the accident. A common mistake: sending medical bills directly to the at fault persons insurance company

• The medical payment claim has to be made formally, by an attorney, to ensure that anything at all is paid.
• The insurance company will only pay the limit of the medical payment coverage, which might be $500.00 to $35,000.00. Therefore the insurance proceeds have to be strategically applied against only the most important and pressing medical bills.
• The attorney is in the best position to determine which medical bills are the most important and pressing. For example, an upcoming surgery might require a surgical suite fee paid in advance, which the victim might not be able to afford. That kind of bill is important and pressing. An experienced attorney will be able to prioritize competing claims to the limited amount of medical payment proceeds.
• The attorney may be able to convince certain health care providers to refrain from collection proceedings until settlement money (or money from a judgment) is available. This is referred to as a “lien,” meaning that the provider has a legal right to be paid from the funds that later come into the attorney’s hands from the injury claim.

The people who work at doctors’ offices are not actually authorized to send claims to the insurance company for the liable party in an injury case — believe it or not. Therefore, the claims are on the wrong forms (there really are no forms for this, because attorneys handle them differently each time), the insurance company gets confused and sends confusing letters to the doctors’ offices, the medical payment coverage limit is exceeded and then nobody gets paid, and generally speaking nothing but confusion and hard feelings result from this. Frequently the doctors feel that the victim has mislead them by giving them incorrect insurance information, and the quality of care can actually suffer.

The victim often is reluctant to use his or her insurance. One fear is that the insurance company will drop the victim. If the coverage is under a group policy, this is not likely to happen.

Clients should normally consider using their own insurance because certain health providers, such as hospitals and ambulance companies, refuse to wait for the settlement or judgment, use bill collectors to harass the victim, and send negative reports to credit reporting agencies. These companies do not consider themselves bound by the ethical precepts of physicians, who take an oath to render medical assistance whenever necessary, even to people who cannot pay, and who therefore routinely enter into arrangements to be paid after the settlement or judgment. The practices of such companies are unfair and unwarranted, and should be changed someday.

You can deal several different ways with creditors like doctors, ambulance companies and hospitals. First choice is to ask them to “accept insurance.” This means that they will take as full payment whatever your health insurance company will pay them.

Beware of something called “full balance billing.” This is best illustrated with an example. If the creditor has an agreement with health insurance companies, that agreement says that the provider can charge you CERTAIN LIMITED AMOUNTS for services. In other words, the regular price might be $1,000.00 but the agreement might say that you get it for $300.00. such bills. Secondly one can ask them to “take a lien” on the “case.” This means that they will agree to not press you for money until the case or claim settles, at which time they will be paid through the settlement. The advantage is that you do not have to come up with the money now (which in any event would be repaid to you out of the settlement). The other advantage is that you or your attorney would have a chance to negotiate (i.e., reduce) their bill. If they agree to this, they will provide you with a form to sign, which you should permit your attorney to review before you actually sign it. If the provider does not have the form, tell them to call your attorney, who will send a form to them.
Third choice is to pay the amount (either the amount that they ask for or an amount that you negotiate), and get reimbursed from the settlement.

If you fail to do any of these things, the likely outcome will be that the matter will be turned over to collections.

When a client has another injury, it is important that the attorney know about it. In fact, it is critically important if the accident caused injuries to the same part of the body. The reason is that the attorney’s presentation to the insurance company and the court will be based on the assumption that the injuries are only from the accident that they are presenting the claim for. If it turns out that this assumption is incorrect, then the case will not be worth what the attorney was asking for.

Many times, there are differences that can be documented, strengthening the client’s case. The foregoing reasons also apply to pre-existing injuries. Sometimes the doctors will confirm that the injuries arising from the accident made a pre-existing condition worse. Therefore, clients must always be frank and open about injuries they sustained before and after the accident in which they are seeking representation.

It is very rare that a person files for bankruptcy because of an accident for which they are responsible. However, it does happen if the liable person either is not insured or does not have assets sufficient to pay the uninsured portion of the judgment. Bankruptcy normally results in a complete discharge of the uninsured portion of the debt to the accident victim. Because of the possibility of complete discharge, it is of the utmost importance to determine whether the liable party or parties are insured. If a defendant is insured, he or she does not have to file for bankruptcy, because the insurance usually is sufficient to pay for the damages.
Mental anguish and emotional distress suffered by the victim, relatives and bystanders The terms “mental anguish” and “emotional distress” are interchangeable. The victim may suffer from a variety of things including but not limited to:

• Anxiety and terror when remembering the accident
• Nightmares
• Fear of driving
• Post traumatic stress disorder (or, if it lasts long enough, post traumatic stress syndrome)

If your clothing or other personal property is damaged in the accident, you are entitled to make a claim for an amount that will compensate you for your loss.
It is difficult to prove what clothing is actually worth, because usually it is not new clothing, and therefore the value of it is far less than it was when it was new.
It is also very difficult to prove what clothing costs, because usually people do not keep the receipts.
If your clothing or other personal property was damaged, make a list of the damaged items and give us that list.
Repayment of medical bills to insurance companies for the victims When a claim is resolved, the victim may be required to repay medical and wage loss insurance payments made under the victim’s policy. Payment to Medical Providers
Although the rights of hospitals are a bit different from the rights of insurance companies, they share a common element, namely that the hospital’s right of payment also may establish a lien on the settlement or judgment.

A lawsuit may be filed if: we do it for strategic reasons, or we do it because the law requires it. There are several strategic reasons for filing a lawsuit:

• To get information that we can’t get informally.
• To take the deposition of an important witness.
• To make an insurance company take notice. Sometimes the local insurance adjuster places a dollar value on it that simply is unfair.  We will file the lawsuit to force the insurance company to retain an attorney for their insured.
• Sometimes we file a lawsuit because the law requires it.  Every state has a law that limits the amount of time in which an injured person can make a claim in court.  If the victim fails to file in time, the insurance company for is not required to pay any money to the victim.  Therefore, even though we may not want to take a case to court, we sometimes have to file it because of this period of limitations.

One of the most important steps in making an insurance claim or preparing a dog bite lawsuit is gathering the medical records. “Medical records” include:

• Ambulance /Paramedic (fire department) records
• Emergency room records
• Hospital records.
• Private physician records of exams, treatment and consultations
• Physical therapy records

The medical records are kept separate from the medical billings. The billings must include the standard codes for descriptions of services, the dates of treatment, and the itemized charges on each date. The billings also must show the gross amounts charged, as opposed to the net charges after receipt of payments or application of discounts.
Copy services charge a significant amount to copy records.

When you suffer a bodily injury, the purpose of the civil justice system is to compensate you. If getting money is your idea of justice, then you’ll be quite satisfied with this system, but if your idea of justice is something else, you will be disappointed, not only with the limited goal of the justice system (i.e., to give you money but not take away your pain), but also with the cost, duration and effort required to reach that goal. You will not get paid what you deserve simply because you asked for money. The nature and extent of your injuries and other losses (like loss of income from your work) have to be proved. This means that there will be two investigations, one by your attorney and another by the insurance company.

No matter how angry you got after your accident, you will actually get past the anger at some point in the future, and that point will come prior to the case being ripe for settlement negotiations. The cost, duration and effort to make a settlement presentation will convince you that you won’t want to endure the cost, duration and effort of getting a day in court. Trials are expensive.

Witnesses are very important in a lawsuit or insurance claim.  Even though the victim may believe that the circumstances of the accident was very clear, there often are two sides to a story. It is important to make contact with the witnesses as soon after the attack as possible. The victim has to provide the attorney with the names, addresses and telephone numbers of all the witnesses.  In some cases where there has been a police investigation, the names of witnesses can be found there.

The policy provides that the carrier has the obligation to settle or defend any claim or suit asking for covered damages. The insuring agreement further provides that, “In addition to our limit of liability, we will pay all defense costs we incur. Our duty to settle or defend ends when our limit of liability for this coverage has been exhausted”. The duty to defend under an automobile insurance policy is subject to the same general principles that apply to a carrier’s duty to defend under any type of liability policy. The policy does specifically provide that the duty to defend ends when the carrier’s limit of liability has been exhausted. In that case, the issue was whether the insurer could refuse to defend a permissive user after it had paid its per person policy limits to settle a negligent entrustment claim against the owner.

The Personal Auto Policy requires the insured to send copies of any notices or legal papers to the carrier. Where an insured has been served with a lawsuit, the insured has the duty to forward the suit papers to the carrier. Obviously, a carrier cannot defend a suit unless it is notified that such a suit exists. It has been held that compliance with the notice provision is a condition precedent to the insurer’s liability on the policy.
When a carrier is not informed that suit has been filed against its insured until after a default judgment has been taken and the judgment has become final, then clearly the insurer has been prejudiced.

The Personal Auto Policy excludes from liability coverage claims arising out of the ownership, maintenance, or use of any vehicle other than your covered auto “which is owned by you; or furnished or available for your regular use.” The purpose of this exclusion is obviously to prohibit the insured from having multiple cars covered under one policy when the insured is paying a premium for only one vehicle.

The purpose of uninsured/underinsured motorist coverage is the protection of persons who are legally entitled to recover damages from the owners or operators of uninsured or underinsured motor vehicles.. In other words, this coverage substitutes for liability insurance normally available to compensate injured persons.

As stated above, the policy requires that the liability of owner or operator of the uninsured or underinsured motor vehicle arises from the “ownership, maintenance, or use of that vehicle”. Obviously, the typical automobile accident is going to arise out of the ownership, maintenance, or use of the uninsured/underinsured motor vehicle.