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How Gaps in Treatment Affect Injury Claims

One of the frustrations many people experience when trying to settle their personal injury claim with an insurance adjuster is trying to figure out what a “gap in treatment” is, and why the at-fault driver’s insurance refuses to pay for some medical treatment. If you were hurt by someone else, and you have medical bills that are the result of treatment you received following the injury, how is it possible that those bills will be your personal financial responsibility, when the reason you have them in the first place is because someone else was negligent? This article will help people who have been injured in a car crash understand what the insurance companies look for.

Treatments to the back, neck, and spine, such as chiropractic and physical therapy care, can sometimes last several months after a car crash.

Treatments to the back, neck, and spine, such as chiropractic and physical therapy care, can sometimes last several months after a car crash.

Chronology of Medical Treatment

Immediately following your injury, which for the sake of using an easy to follow example, we’ll say was the result of a car crash. The law in California is that the person who hurt you must make you “whole” again, or put you in as close to the same condition you were in before the car crash. This means physically, emotionally, financially, and sometimes even socially. So if you were hurt, and you seek medical treatment, it follows that the person who hurt you should pay for your medical bills, right? Yes, and no. The at-fault driver is responsible for reasonable and medically-necessary treatment. So the insurance company can deny payment for medical treatment you receive that they say is not the result of your injury, in this example a car crash.

The most common way an insurance adjuster will deny payment on medical bills is by saying there was an unreasonable gap in treatment. If you wait too long to receive treatment, they will argue that you weren’t really hurt, and that treatment you receive after a gap is not really their insured’s responsibility. So what should you do to make sure the insurance adjuster doesn’t refuse to pay your medical bills by saying you waited too long to treat your injury?

Proper diagnostic studies, such as an MRI, can help avoid gaps in treatment. If you know the severity of the injury, you're better equipped to treat it properly.

Proper diagnostic studies, such as an MRI, can help avoid gaps in treatment. If you know the severity of the injury, you're better equipped to treat it properly.

The first thing any injury lawyer will advise their attorney to do is get a medical checkup as soon as possible. If you’re hurt, go to a doctor. Go to an urgent care, or an emergency room, if necessary, but if you were injured, you need to have a medical professional document the nature of your injury. From there, you should follow the advice you are given. For example, if you go to your primary care physician and he or she tells you that you require an x-ray, or an MRI, then it is your responsibility to follow up and get the care they tell you is needed. If you don’t do what your doctor says, the insurance companies will say you were non-compliant with recommended treatment. This hurts your claim, and as it relates to the outcome of your case, it is more likely you will receive less compensation during the settlement phase of your injury case.

What is a gap in treatment?

Our office has seen insurance adjusters claim that delays in seeking the advice of a doctor for as little as three days after a car accident is unreasonable. More common, any delays of more than five days after a crash will certainly be disputed, and the longer you go in between treatment, the worse it will be for your case. This can be difficult for single parents and anyone who works, as taking off work, or scheduling a babysitter to make it possible for you to visit a doctor and receive the treatment you need is sometimes a difficult obstacle. A good injury attorney will be able to successfully argue that any gaps were not only reasonable, but that you did everything you could to follow up on medical treatment. After all, the injury was not your fault in the first place, so you should not have to turn your life upside down to go to the doctor.

What is a proper treatment sequence?

If your primary care physician says you need chiropractic care, or physical therapy, generally the minimum number of appointments you should plan on attending is one per week; gaps of more than one week can hurt your claim. Of course, life happens and it can be hard to stay consistent with treatment. The medical benefits of going to a chiropractor or physical therapist are greater if you go more frequently; a good chiropractor or physical therapy office will be able to work around your scheduling conflicts, and give you therapy you can do at home to help alleviate your pain. Most personal injury law firms in California are aware of the good chiropractors and physical therapy offices that help people recover from car accidents, as well as those who perhaps have a reputation of not helping their patients reach a full recovery.

what if I need to return to treatment after a gap?

Unfortunately, many people have no choice but to return to treatment, such as a chiropractor or physical therapist, not because their schedule was crazy or they were being lazy, but because their symptoms/injuries returned. That is, after a sequence of treatment at a chiropractor or physical therapist, the doctor says let's see how it goes, and after a few weeks, you realize you are still suffering from pain from the car crash. Most doctors put in their notes that this may happen. This is often referred to as a flair up. Insurance companies do whatever they can to deny paying for these kinds of treatment. In many cases, the only way you'll successfully get them paid for is by hiring an attorney. In fact, this is a common reason people seek advice from an injury lawyer - they have a need to continue medical treatment for their injury, but the at-fault driver's insurance is saying they won't cover the bills.

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Can an Injury Attorney Help?

It is hard to imagine a circumstance where contacting an injury attorney after a car crash would be a bad idea. If nothing else, you'll be able to ask the questions you're wondering about, and get the advice from someone who works on this type of legal case every day. Gaps in treatment can hurt your claim, but not all "gaps" that insurance adjusters deny are fairly denied. Keep in mind that the best attorney to answer your question may not be in town. This is normal, and most injury firms that practice exclusively injury law in California represent clients throughout the state. If you live in a rural area or small town, chances are the best injury lawyer to consult with is not close by. However, many law firms in areas of California with greater populations, such as Orange County and Los Angeles County, are able to fully service clients that live within the state of California, with ease using technology. 

 

"You Don't Need an Attorney for Your Car Crash Injury Claim"

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For personal injury attorneys in California who practice exclusively injury law, it is only a matter of time before they take a case where the client was told at one point by someone at an insurance company that they didn't need an attorney to help them. The longer injury lawyers practice, the more frequent this story becomes. Clients are told shortly after their car accident by the other driver's insurance company that they "don't need a lawyer for this kind of claim." Because this advice has drastic consequences, a brief look as to why an employee of an insurance company, especially an injury claim adjuster, would say this is worth looking into.

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What Do Insurance Adjusters Do?

Insurance adjusters evaluate claims and, if necessary, offer money to settle the claim. What does "settlement" entail? It basically means that in exchange for money, the claimant will not sue the insurance company's insured in a court of law. This all happens before any lawsuit is filed against the person who caused a crash. Insurance adjusters are therefore middlemen that are supposed to protect the interests of their insured. The more claims an adjuster can settle or close, the better they are at their job in the eyes of their bosses, and they are often compensated accordingly. In short, if an insurance adjuster can get you to settle your claim, they win, and personally it is good for their careers.

What Exactly Does "Evaluate Claims" Mean?

Insurance adjusters evaluate claims. Basically this means they investigate what the claimant is saying in comparison to what their insured says. However, their evaluation is not objective, whereas a jury evaluation of a case is supposed to be objective. If the insurance adjuster's client/insured says they didn't cause the accident, the insurance adjuster will stick by their client, regardless of what the facts say. This means they can deny your claim, even though there's a lot of evidence to show that their guy is at fault. So even though they are tasked with evaluating the claim and trying to get the claimant to go away, their view favors the interests of their company.

Why Don't Adjusters Want Me to Speak With an Attorney?

First, remember that insurance adjusters are expected to move files off their desks. The quicker they can get rid of your file, the sooner they can move on to the next file, and so on. The involvement of an attorney does not necessarily mean your claim will go unsettled longer, but it most certainly means that when your claim settles, it will be for more money. Injury attorneys specialize in getting their clients money, plain and simple. The money comes from the at fault party's insurance company. In short, if an attorney is involved, the insurance company is going to have to pay more money to make the claim go away. This is bad for the individual insurance adjuster's performance metrics.

Insurance adjusters also handle so many car crash cases that they become accustomed to getting their way with plaintiffs who are not represented by an injury lawyer. They get used to having the upper hand in the negotiation, and they are used to getting their way. They also know that the tables turn when an injury law firm is involved, as an experienced injury lawyer will know far more about the law, case results, and how the courts actually work.

The Insurance Company says ________________. Is this true?

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Insurance adjusters are not bad people, but they do have often have a narrow perspective as to how an injury case might play out if an attorney is involved. Again, they settle so many cases for pennies on the dollar that they don't realize a case they settle for $500 may be worth $15,000 or $50,000 if an attorney is involved. They view themselves at injury authorities, even though they are not trained in the law, and don't know what happens to cases that they don't settle that end up in litigation and going to trial. Insurance adjusters therefore often try to coach claimants as to how the process works, even though their approach is heavily favorable to the insurance company's bottom line, and geared towards low settlement.

"My Adjuster is Very Friendly. I Don't Want to Cause Problems for Anyone."

Friendliness is a proven negotiating tactic that is taught to insurance adjusters in most insurance companies. Hint: if you've seen a commercial on television for an insurance company, you can rest assured the adjusters for those companies have all been trained how to present themselves in a friendly manner during negotiations with claimants. Also, remember that none of this is personal. You will never meet the insurance adjuster, and even in the event that your case requires a lawsuit be filed, you will probably never see the individual who injured you again. The insurance policy is there to protect you in the event of injury, and so when you are injured by someone else's careless or reckless driving, the law has provided a way for you to recover, physically and financially. 

If you pursue your claim, it is extremely unlikely that the actual individual who hit you will know or care how much their insurance company settles for. For example, an auto insurance policy for $50,000 covers your injuries up to that amount. Whether you settle for $500 or $50,000, it does not affect the person who injured you personally, as the money comes from the insurance agency. This is why we pay insurance premiums. Every month, every California driver pays money to be insured. In return, if they cause an accident and hurt someone, that money is used to protect the negligent person. Thus, your efforts to get a fair settlement and have your medical bills and pain and suffering paid for have nothing to do with the individual who hit you, but become the responsibility of the insurance company to resolve.

Isn't All This Overly Skeptical of Insurance Companies?

The more injury claims an attorney sees, the more aware he or she is of the many ways in which insurance adjusters are able to convince injured people to do things that will ultimately result in the claimant receiving less money. Insurance companies are insanely profitable, as evidenced by their high profile advertising campaigns, the stadiums their brands are on, and their pervasive presence in advertising culture. Insurance companies spend billions of dollars every year in advertising, and in return, they earn billions of dollars in profits. If you are injured and want to get your medical bills paid for, that is why the insurance policy exists, and why California law requires drivers to have insurance. Insurance companies employ good people, and are not necessarily corrupt, but they do have a bias, and that is to settle all claims for as little money as possible, as this is how they stay profitable.

If You Are Injured

California law provides for full recovery if you were injured, meaning you should be in the same position you were after the car accident or other injury-causing accident as you were before the accident. If your injury is long-lasting, catastrophic, or permanent, this may not be possible. Still, the law makes sure the negligent/at fault person is responsible for making you whole, so if you can't be put back together, you are owed money for pain and suffering. The Lions Injury Lawyers are passionate about getting fair value for injury claims. They fight endlessly to recover as much money as possible for their clients, which will cover all medical expenses and also include money for pain and suffering, lost wages from time off work, and money for other incidental and inconvenient or painful lifestyle changes. The Lions Injury Lawyers spend 100% of their time practicing injury law, and are exclusively dedicated to personal injury clients. Speak with an actual injury attorney today to make sure you're not being taken advantage of as you seek to settle your claim.

Car Accident Injuries & Medical Bills: What Insurance Will (and will not) Pay

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The range of injuries that result from car accidents varies greatly, from minor scuffs and bruises, to catastrophic injuries that require extensive hospitalization, surgery, and other intense medical treatment. If you were injured in a car accident in California, the laws essentially state that you are entitled to be made whole again, or to receive the medical care necessary to bring you back to the same state of health you were in prior to the car crash. The person who hit you is responsible for paying these medical bills, in general, but there are many "loopholes" that make getting full payment of your medical bills paid for difficult or impossible. 

How Does Insurance Evaluate Medical Care?

An injured person is expected to pursue reasonable medical treatment to care for their pains and ailments. What is reasonable? The answer to that question is, of course, subjective and it depends on who you ask. Generally speaking, medical care is considered reasonable by insurance adjusters if it happens at an appropriate time in relation to the car accident, the number of visits are within a normal range, and the cost of the care is within what insurance companies define as "industry standard." Some insurance companies are more strict than others when defining a price point for industry standard, which means they will not pay for treatment over a certain dollar point, regardless of where you live or how soon after your car accident you sought medical treatment. This situation leads many injured people to seek the advice of an injury attorney, even just to review their case and get advice on how to move forward.

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The Cost of Medical Treatment

Some insurance companies look to what Medicare accepts as "normal" pricing for a medical treatment or procedure. Obviously this is the lowest number possible for any given medical care, and the average car accident victim is unlikely to receive any medical treatment at the Medicare price. Does this mean you have to shop around endlessly to find the absolute cheapest medical care to treat your injuries? No. It may mean you'll benefit from the representation of a lawyer who practices car accident law, or an injury law firm that can assist you in finding access to medical care that will get you on your way towards full health. A good lawyer will fight to make sure you get your medical bills paid for and also compensation for pain and suffering.

Sequence Matters in Medical Treatment

Another way in which medical bills are slashed or denied by insurance companies is by the insurance adjuster claiming there was a "gap in treatment," or improper sequencing of care. This means that if you are hurt, you need to get help right away, and then follow the advice of your doctor. If you're injured, you need to first see a qualified doctor, and then follow the regimine the doctor prescribes you until you are better. If you take long breaks in-between treatment, you may find it difficult or impossible to get your bills paid for due to gaps in treatment. Similarly, if you know you require surgery, for example, you can't just delay getting the surgery for months and years. At some point, and it varies case by case, the insurance company will say the surgery is not related to the initial accident, and they will deny liability to pay for the operation. Sequence matters. This means you should seek the opinion of someone able to give an assessment of your injuries or ailments, like the kind of doctor visit you might get at an emergency room, at an urgent care, or through your primary care doctor. Then, you're expected to follow the advice of the doctor. For example, if the doctor says you need 25 visits of chiropractic care, you will be expected to go to a chiropractor and receive that amount of care.

Chiropractic care can be especially tricky when seeking payment for your medical bills from the insurance company of the individual liable for the accident and your injuries. Most insurance companies will balk at paying for more than 25 visits, unless specifically prescribed by a doctor not affiliated with the chiropractor's office. After 25 visits, if you are still injured, you'll be expected to seek additional treatment, something more advanced, such as an MRI, or a visit with a pain management office, or a specialist that deals with the body part(s) you've suffered injury in. 

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Don't Accept Pennies on the Dollar for your Bills

Some people injured in a car crash or other injury that was not their fault feel helpless when the insurance adjuster offers them a couple hundred dollars to pay for large bills. Feeling helpless, they don't know what to do and accept the money, thinking something is better than nothing. This plays perfectly into the insurance companies' strategy: if you offer ten people a very small settlement, at least seven or eight of those people will either go away, or eventually accept it. Dollar for dollar, this is their best bet, and they save the most money by doing this. What the seven or eight people who accept this offer do not know is that if they're offered $500, there is likely at least a couple thousand dollars available to pay for their bills, but they don't know how to get it.

Getting to a "Fair and Reasonable" Settlement for Your Injury

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If you weren't at fault, but you were injured, you deserve compensation to pay for your bills and for your pain and suffering. While the law says you deserve this, and there are tens of thousands of cases where this happens, most people don't know how to go about getting this money, and without the assistance of an experience and trusted injury law firm, you're very unlikely to get the money you deserve for your injury. Experience matters in injury law, and the representation of a good lawyer will, in almost every case, mean the injured person walks away with more money in their pocket and their medical bills paid for, than if they try to negotiate on their own. This has nothing to do with how smart the injured person is or how good a negotiator he or she is. If you don't know what your case is worth, or how the insurance company reviews your file and comes up with a price tag, you will not be able to get to their top offer. Of course, you can threaten to sue, but insurance companies are well represented by good defense law firms, so they are not intimidated by threats of lawsuits from individuals saying they'll go it alone and file the lawsuit. An injury law firm, on the other hand, will not only file a lawsuit on the injured person's behalf, but they'll go about it the right way and will very likely increase the cost of your claim by a lot of money: a lawsuit from a plaintiff represented by a good injury lawyer will get the attention of any insurance company or insurance adjuster.

The Lions Injury Lawyers, P.C. represents injured clients throughout California. Based in Orange County, CA, The Lions practice only injury law, meaning they focus 100% of their time, energy and effort on winning money for injured people throughout California. No matter if you live in San Diego County, Orange County, Los Angeles County - or somewhere else in California, The Lions will vigorously fight for you and your case. You won't talk to a salesman if you call for a free consultation - you'll discuss your case with an actual attorney, a lawyer who may eventually represent you and help you recover from your injury. Lawyers are ready to discuss your case today, or simply answer your questions.