The Adjuster Is Investigating My Claim. Do I Need a Lawyer, or Can I Settle My Injury Claim Without Hiring an Attorney?

The Adjuster Is Investigating My Claim. Do I Need a Lawyer, or Can I Settle My Injury Claim Without Hiring an Attorney?

Topics of Interest:
Attorney's Fee in injury cases
Settling Injury Claims
Adjuster is Delaying Payment and "Investigating" Claim
Medical Care After an Accident
Notice of Hospital Lien Against Case
Should I Use My Health Insurance After an Accident?
Multiple Car Accidents and Injuries
What You Can Recover in Injury Cases

The insurance adjuster is telling you that it needs to finish its investigation before it can pay anything on your injury claim or accident.  Should you be worried?   In short, yes, at least a little worried. 

Most of the time, you should probably consider calling and consulting a law office that handles personal injury cases before trying to settle a personal injury case on your own.  The phone call is free.  Good law firms will ask you the questions that are relevant to settling an injury claim.  If your case has serious problems with it, they will not take your case, and most attorneys will let you know what they think the problem with your case is – so you are not surprised when the insurance adjuster brings up this issue when negotiating the claim.  
If you have an injury that has caused serious injury or financial difficulties then the attorney may want to represent you.  In the conversation with the lawyer, you may discover reasons that make you realize you need an attorney in your situation.  On the other hand, you may decide to go forward on your own (I never recommend this with a serious injury case, or where the medical bills or other damages are high, but it is your case and your decision).  
If your auto insurance company is delaying payment on your claim because it has not "finished its investigation" then you are on notice that they are looking for a reason to get out of paying your claim.

Just as a bit of background, I used to be an insurance claims adjuster.  I worked at GEICO for 7 years and handled personal injury claims for them.  Adjusters are trained to handle claims in a particular order. 

First, the adjuster will determine if there is coverage.  Just because the other driver had their insurance card does not mean there is coverage for this particular claim.  The adjuster looks to see if payment was made, if the correct vehicle was used, if the vehicle is being driven by the correct person, if the vehicle was being used for a purpose that voids coverage, if the person driving the vehicle was licensed, and the list goes on.  If there is a reason to deny coverage, then they will not pay the claim. 

Just because they paid for part of your claim does not mean they won’t come back later and deny coverage.  They can pay for your vehicle, and then later on, while investigating your injury claim, discover some fact or issue that voids coverage.  For example, they may not realize in the beginning investigation of the claim that their driver was using their car for “business purposes”, such as delivering pizza.  If they find out later that it was being used for business then it becomes a problem.  If the vehicle was being used for business, they will deny coverage for the injury claim, even though they already paid for your car’s damage. 

Next, after confirming if there was coverage, the adjuster looks at liability.  In other words, was their driver at fault?  Were you at fault?  Was someone else at fault?   Was nobody at fault?  They will try to find a way to say that their driver is not at fault, or find a way to put at least some of the blame on someone other than their driver in order to reduce the amount they will owe. 

Finally, they will look at the damages.  Damages are what harms and losses were incurred due to the accident or injury.  Examples are medical bills, lost income, damage to your vehicle, rental bills, towing bill, pain and suffering, disability, disfigurement, wrongful death, mental anguish, and other losses and harms caused by the accident or injury.  They will review any bills, estimates or receipts to verify they are related to the incident in question, and not due to some other reason.  If the documentation isn’t clear, or if there is a large gap in time, the adjuster may claim that he doesn’t believe your documentation (bills, estimates, or receipts) are related to the accident or injury in question.  The adjuster will see if you did your part to minimize the damages (called “mitigation of damages”).  A person is required under the law to try and keep their damage to a minimum if possible.  The insurance adjuster will verify that the amounts claimed are reasonable.  Did your medical provider or body shop charge an excessive amount compared to what is normally charged?  Are the medical providers or body shop charging for something that didn’t need to be done?  If so, the insurance adjuster will try to deny covering that part of your claim – leaving you to pay that part of the bill.  Often insurance adjusters claim that some part of your claim was excessive, but give you no guidance on how they came to this opinion.  This leaves you with little or no help in dealing with your medical provider or body shop when they are asking for payment.  You can’t just tell them “your bill is too high” and expect the medical provider or body shop to accept that.  But that is what insurance adjusters often do when evaluating claims. 

So if your insurance claims adjuster is delaying paying your claim because they need to “finish their investigation”, then this can mean multiple things, but it all boils down to one thing . . . they are trying to delay paying your claim.  

As discussed above, investigation for an insurance company is done for the following reasons: a) coverage issues; b) liability issues; c) damages issues. 

a)  Coverage Issues:  If they are investigating a coverage issue, then this means they are looking for a reason to say there is "no coverage" and then deny your claim.  Like discussed before, it can be for non-payment, for a person driving their car who was not supposed to be driving it, for the other person driving a car that was not listed, for no coverage for the time or date of the accident, for their driver "not cooperating" with them - meaning they aren't calling in the claim.  Yes, they can deny coverage because their driver never calls in the claim - getting the insurance company off the hook for paying your claim.  They "want" their insured driver to not call.  This gives them an excuse to delay paying you and hold on to the money just a little longer, and gives them an excuse to deny coverage at some point in the future in case their person never does call in the claim.  

b)  Liability Issues:  If the insurance adjuster has told you that they need to “confirm liability”, or that they need further investigation regarding liability, this means they are looking for reasons to place the blame on someone other than their driver.  They may try to place the blame on you, or your driver for something they claim you did (didn't put on your brakes in time, cut them off and then slammed on your brakes, failed to veer right or left to avoid the collision, didn't use your horn so the other person would know to get out of the way) . . . or maybe they will try to blame a "phantom vehicle".  Often, the other driver will claim that some vehicle that nobody else saw suddenly cut them off and they had no choice but to hit your vehicle.  They will claim that it wasn't their fault, but the fault of this "phantom vehicle" that nobody saw, and nobody has a license plate for.  This will give the insurance company an excuse to try and deny your claim. 
Sometimes they will blame it on God himself.  They call it an "Act of God".  Acts of God include weather, sun, wind, rain, or ice.  Everyone on the road may be driving normally, and within the limits that the weather dictates, but their driver has decided to drive too fast for the conditions, or change lanes when unsafe and loses control on the water, or gets sun in his eyes, and tries to place the blame for the accident on an Act of God.  This gives the insurance company a reason to deny liability, because their driver did nothing wrong - it was Mother Nature, or God who caused the accident. 
 c)  Damages Issues:  If the insurance company is waiting to pay because they have to confirm some issues about "damages" (medical treatment, lost income, or other out of pocket expenses), then they are looking to see if they can find a reason to not pay your damages (medical bills, lost income, or other out of pocket expenses).  If you had another accident or injury claim with another insurance company from an auto accident, or from a Workers Compensation claim, or from a premises liability case or slip and fall, then they are likely contacting those other insurance companies to see what injuries you had in those older cases to see if your injury you are claiming now is similar.  If it is similar at all, they will try to blame your current injury on your old accident or injury, and claim that they do not owe it.  Insurance companies have access to databases that let them know about all your other injury claims you have had, with all the different insurance companies you have made any claim with.  They will know about any prior claims of injury, even if it was just a minor complaint, and they will use that information against you and try to blame your current injury on the old claim - in order to get out of paying. 
In summary, if the insurance adjuster is delaying payment on your claim due to "investigation" reasons, you should contact a lawyer.  Tell them what is happening.  The call is free, and you might learn something that helps you get your case resolved.  If you have a serious issue, and the attorney can help in your situation, they will offer to represent you in your case.  At this point you can determine if you want to accept this help.  If you don’t want to hire the attorney, at least you have discussed the issues with someone who handles these types of cases on a daily basis, and will have more knowledge about what is happening that before you called.  The insurance adjuster is looking for a reason to get out of paying - coverage, liability, or damages - they are looking under each rock to see what they can find, and if they find something, they will use it against your claim.  Always look to protect yourself.  If you have a serious injury, then you have serious financial problems caused by the accident or injury.  These financial problems don’t handle themselves.  With the different insurance companies involved (auto, liability, health, workers comp, Medicare, Medicaid, etc.), the rules and requirements are complicated and trying to deal with this on your own can cause you even more problems if you don't deal with them properly.