In Personal Injury by GWAO


Medical records and bills are the two main types of documentation that an insurance adjuster considers when determining the settlement value of a personal injury case.  Medical records are forwarded to an adjuster as part of a settlement demand package, in order to document that a person was injured in an accident and that he or she received follow-up medical care and treatment as a result.  Medical records typically outline the treatment regimen, diagnosis, and any prognosis for future treatment as a result of the injuries sustained.

Remember that the adjuster’s goal is to minimize the amounts paid out on claims.  One way adjusters do this is by looking for various inconsistencies – or “red flags” – in an injured person’s medical records.

In this post, we will explore some of the more common types of red flags that trained insurance adjusters look for in medical records. With the help of an experienced Garrett, Walker, Aycoth, and Olson Greensboro personal injury attorney, you can minimize the impact of, or altogether eliminate, these red flags from your records and maximize the settlement value of your claim.

Gaps in Medical Treatment

Taking time off work to attend doctor and physical therapy appointments can be difficult if you have children, family commitments, and other scheduled events.  However, significant gaps in your medical treatment are red flags for insurance adjusters who are reviewing your medical records and making a settlement determination.

The most important timeframes in a person’s medical records are:

1) The time period beginning with the occurrence of an accident and ending with medical treatment at a hospital or emergency care facility;


2) The time period beginning with the emergency medical visit and ending with the first follow-up medical visit.

From the standpoint of the insurance company, if an individual claiming injuries is not initially treated at a hospital or emergency care center, or receives initial medical care several days after the accident, then that person must not have been all that severely injured in the accident.  Similarly, if a person receives emergency medical care after the accident, but delays follow-up treatment for weeks or months after the accident, the insurance company may argue that the claimed injuries resulted from a subsequent accident, or that the person was not as seriously injured as he or she claims.  The same holds true when an injured person fails to treat on a regular basis, does not follow through with treatment regimens, or regularly misses doctor or physical therapy appointments.

How can you eliminate this red flag from your records?

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Be a good and compliant patient.  Specifically:

  • Seek emergency medical treatment as soon as possible after an accident;
  • Continue treating with a healthcare provider on a regular basis;
  • Follow through with all of you healthcare provider’s treatment recommendations;
  • Complete all treatment regimens and protocols; and
  • Attend all doctor and physical therapy appointments consistently and on time.

It may also help to keep a detailed personal record or journal of all medical care and treatment as a back-up.

Prior Injuries and Preexisting Medical Conditions to Injured Body Parts

When reviewing an injured person’s medical records, insurance adjusters are trained to look for evidence of prior injuries and pre-existing medical conditions related to the body parts allegedly injured in the accident.  When adjusters see evidence of prior injuries and preexisting conditions in a person’s medical records, they tend to think that those injuries are degenerative in nature or that they pre-dated the subject accident.

An experienced personal injury attorney will know how to present any pre-existing medical conditions in the most favorable light.  For example, your attorney may be able to argue that although your shoulder was injured prior to the subject accident, that injury was worsened or exacerbated by the accident, and, as such, it is compensable and should be considered by the adjuster as part of your damages.

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Incomplete Medical Records

Generally speaking, insurance adjusters are very skeptical of a claim when medical bills are included in a settlement demand package without their corresponding medical records. In fact, many insurance adjusters will not even consider a medical charge if no corresponding medical report is provided for that charge.

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To eliminate this red flag, a smart injury lawyer will ensure that, for every medical bill in your settlement demand package, there is a corresponding medical record which describes the treatment provided, the medical diagnosis, and the likelihood and extent of any future medical care and treatment.

Inflated Medical Bills and Overly Exaggerated Injuries and Symptoms

Insurance adjusters become skeptical if they feel that an injured person received excessive medical treatment for his or her injuries.  For example, if a settlement demand package reflects extremely high medical and physical therapy bills when the claimant suffered only soft tissue injuries in an accident, the insurance adjuster will be wary.

One way to eliminate this problem is to be honest and as accurate as possible in describing the nature and extent of your injuries, your pain levels, and your symptoms to your doctor(s) during the course of your treatment.  You may think that by exaggerating your injuries, you are helping your personal injury case.  More often than not, however, the exact opposite is true.  Claims adjusters are trained to poke holes in personal injury cases, and they will immediately recognize when claimed pain levels and symptoms seem inconsistent with the nature and extent of the claimed injuries.

Lawyer-referred Medicine

If your primary treating doctor has an ongoing referral relationship with your attorney or his or her law firm, the insurance company will view your medical records and bills skeptically.  In the case of so-called “lawyer-referred medicine,” adjusters suspect that the medical bills and the nature and extent of the medical treatment are purposely inflated in order to increase the settlement value of the claim. Avoid this red flag by seeking medical treatment with a family doctor, a primary care physician, or a healthcare provider who does not regularly accept referrals from personal injury attorneys.

Contact Us

While there is no such thing as a medical record entirely free of red flags (most trained insurance adjusters will find at least one!), a personal injury attorney can help you avoid these pitfalls and present a compelling settlement demand package for a Greensboro Personal Injury Attorney. If you would like to talk about the specifics of your situation, please call us at (336)-379-0539.