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rear ended, trouble with insurance adjuster

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kraypm

Junior Member
Hello all,

Brief explanation:

I was rear ended in Nov. of 2004. After months of therapy that didn't take away the pain, I was referred to an orthopedic surgeon that did an MRI and discovered shoulder surgery would be necessary.

I had the surgery in June of 2005. Until yesterday, I have had no problems with the adjuster for the insurance company of the lady that hit me. Suddenly, her insurance company can't understand why I needed surgery at all, and has become uncooperative in closing this claim. They feel the accident was minor, and I have "faked" the need for surgery??? Sure. They are just now contacting the surgeon for info and MRI results.

Bottom line - I was rear ended, I didn't need surgery BEFORE the accident, as "minor" as it was....[car damages only $400], but nonetheless, the other driver was at fault.

I am not sure where this will go, but am sensing resistance from her insurance company. I need to know what happens if they 'kick back' the claim, after my health insurance has paid for the surgery. I am in personal debt in the amount of $4000.00 for copays, therapy, drugs, etc.

Anyone had this sort of thing happen?

Thank you!!
 


S

shell007

Guest
kraypm said:
Hello all,

Brief explanation:

I was rear ended in Nov. of 2004. After months of therapy that didn't take away the pain, I was referred to an orthopedic surgeon that did an MRI and discovered shoulder surgery would be necessary.

I had the surgery in June of 2005. Until yesterday, I have had no problems with the adjuster for the insurance company of the lady that hit me. Suddenly, her insurance company can't understand why I needed surgery at all, and has become uncooperative in closing this claim. They feel the accident was minor, and I have "faked" the need for surgery??? Sure. They are just now contacting the surgeon for info and MRI results.

Bottom line - I was rear ended, I didn't need surgery BEFORE the accident, as "minor" as it was....[car damages only $400], but nonetheless, the other driver was at fault.

I am not sure where this will go, but am sensing resistance from her insurance company. I need to know what happens if they 'kick back' the claim, after my health insurance has paid for the surgery. I am in personal debt in the amount of $4000.00 for copays, therapy, drugs, etc.

Anyone had this sort of thing happen?

Thank you!!
Is it safe to assume that you are handling these negotiations on your own?

Since your injury was severe enough to require surgery, a personal injury attorney should be involved.
 

kraypm

Junior Member
waiting it out

Yes, I am doing this alone. I am waiting to hear back from the adjuster. He says he has been trying to reach my surgeon for an explanation of my surgery.
 
S

shell007

Guest
kraypm said:
Yes, I am doing this alone. I am waiting to hear back from the adjuster. He says he has been trying to reach my surgeon for an explanation of my surgery.
My opinion from my own current similar situation is that their insurance co is going to low-ball you no matter what your Doc says.

Trying to handle this on your own (unless you are experienced in this sort of thing) is not a good idea at all. Even the best PI attorney's have difficulty convincing the opposing side that their client's injuries are a direct result of a MVA, not matter how "black & White" they may seem. However, they(PI attorney) has a much better chance of prevailing than a "layman" does.

I would suggest you contact a PI attorney and explain the details of your case. I would not sit on this though...your SOL for personal injury may be up soon. I would have looked it up, but I don't know what state you are from.

Google: Statute of Limitations personal injury "INSERT YOUR STATE"
 

stephenk

Senior Member
What was the diagnosis that led to the surgery? Was the surgery successful? Did your doctor tell you that the reason for the surgery was solely a result of the accident or a combination of accident and degenerative condition?
 

fejee

Member
Being at fault doesn't necessarily make one legally liable for any damage claimed by the not at fault party. Don't forget, the burden of proof rests with you. I believe in your case, "Causation" is what would eventually influence the dollar value of your claimed injuries.

And by Causation I mean you have to convince the insurance carrier that the proximate cause of your shoulder injury and the resultant surgery was this $400 impact. On the same token, the insurance adjuster's task will be to show that there exist NO Casual Connection between this $400 impact and your claimed shoulder injury. Most likely relying on a
bio-mechanical expert who will say this was not an injury producing accident.

Based on the mechanics of your accident (a rear ender) and the minor damages sustained to both the cars, the adjuster disputes ur claimed shoulder injury. How did u injure ur shoulder in this accident? Is it possible that your shoulder injury was pre-existing? That this accident caused a severe exacerbation or aggravation of this old shoulder injury to the extent that it necessitated surgery?

Your medical records should clearly show that all your doctors point to this accident as being the proximate cause of ur shoulder injury. Or that it was the cause of aggravating an old injury which prior to this accident was asymptomatic.

Dealing with such complex injuries would be best handled by an experienced attorney. Have u already made a demand to settle ur claim? A policy limit demand may be in order for the type of injuries u claim.

Good luck in resolving ur claim.
 

goodgrief

Member
Just an FYI how your doctor "words" your dx is going to be EXTREMELY important to your case. It has to show that your shoulder injury is a direct result of this accident.

I was in a similar situation in 2004. The driver who hit me totalled my car, I was taken to hospital, MRI's done, physical therapy...blah blah. I hired a very well known personal injury attorney in these parts and still ended up getting the short end of the stick. I finally settled, against my better judgement, in December of 2005 and to this day I still have L shoulder pain.

I agree with posters who said you do need an attorney to handle this if you are not familiar enough with the proceedings, but word of caution make you sure you stay well informed of what your attorney is doing and ask as many questions as you possibly can. Also, shop around for your attorney...ask people in your area, the more informed you are the better your outcome will be.


Good luck to you!
 

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