Last Update: 5/15/23
In Florida, when an injury victim opts to negotiate a personal injury claim with the insurance company on their own, he or she needs to be prepared to deal with sophisticated adjusters who strive to keep settlements as low as possible.
Insurance adjusters are trained to negotiate settlements in the insurance company’s favor. This means that a victim will likely be in a position of unequal bargaining power. That discrepancy of bargaining power is what usually leads to a dispute when it comes to a personal injury settlement.
To help level the playing field between accident victims and insurance companies, we created a free guide for those Florida accident victims who wish to negotiate their insurance claims on their own. You can download our free e-book on settling a Florida personal injury claim without a lawyer here.
Common Reasons Why The Parties Disagree and Are Unable to Settle a Florida Accident Claim
For an accident victim, preparation, organization and honesty are the keys to settling a personal injury claim on their own. Knowing in advance some of the common issues that may surface in a settlement dispute can be very helpful. In our experience, you may run up against the following:
1. Causation
One of the most common disputes an insurance adjuster will use is regarding causation. So, a question you will have to ask yourself is, “what caused the car crash, or the slip and fall?”
As the claimant, you will not only have to provide proof of the accident but also provide proof of what caused the accident to occur. By providing convincing evidence of causation, you will have a better claim against the insurance company and the at-fault party.
For more information, read: What is Concurrent Causation?: Determining Who Pays Damages For Your Injuries When More Than One Person is Negligent
2. Fault
After you have established the cause of the accident, the next question from the insurance company will involve fault. Who was at fault? Who caused the car crash, or slip and fall accident?
Your claim will need to explain why their policyholder is at fault for the accident. Facts will need to be presented to show that their policyholder made a mistake that ended with you being injured.
In legal terms, you will need to show that their policyholder had a (1) legal duty to you that (2) was breached and (3) caused your harm.
What you need to do here will depend upon your type of accident. Car crashes will be treated differently than slip and falls, for instance.
Also, expect a dispute over whether or not your own actions caused, or contributed, to the accident. The insurance adjuster may argue that you were at fault, at least partially. This will lessen the amount of damages that the insurance company will have to pay on your claim.
In Florida, this legal concept is known as comparative fault.
For more, read:
Fault, Blame, and Damage Claims: Contributory Negligence in Florida
(Update: Florida replaced its pure comparative negligence system with a modified comparative negligence system. Consequently, a personal injury victim can now recover in proportion to the defendant’s percentage of responsibility only if the victim’s own share of responsibility is 50 percent or less. If the victim bears more than 50 percent liability, the victim cannot recover from the defendant.)
a. Premises Liability
In Florida, slip and falls are also known as “premises liability” claims. Florida’s premises liability law imposes legal duties upon business or property owners.
For example, the owner or operator of the property where the slip and fall occurred has a duty to keep the premises reasonably safe for invitees, clients, customers, and guests (the duty owed to an invitee varies depending on what caused the slip and fall – was it because of a transitory substance on the floor of a grocery store?).
Disputes often arise as to the duty owed to the victim as well as whether or not the business owner acted reasonably and/or had knowledge of a dangerous condition.
a. Car Accidents
Often, in car accidents the insurance company will dispute who caused or who was at fault for the accident – it is important to know how an insurance company determines whether or not a driver was acting reasonably at the time of an accident.
For more, read our posts including:
How Do You Know If A Driver Acted Reasonably In Trying To Prevent a Loss of Control Car Accident?
How Do You Know If A Driver Acted Reasonably In Trying To Avoid A Rear-End Car Accident?
3. Amount of damages
Accident claims consist of two parts: (1) liability and (2) damages. To prove liability, the victim must show the policyholder was responsible or at-fault for the accident. To prove damages, which is the compensation a victim receives to make them whole again, the victim has to provide documentation and, in some instances, expert testimony.
Damages are legally defined under Florida law. When a victim files their own accident claim, they should know what damages are recoverable, which can be economic or non-economic in nature.
The insurance company may dispute your claim by saying that you were not hurt as bad as you say you are or that you were not hurt at all.
For more, see our related articles:
4 Factors Used To Determine The Amount of Damages Suffered By An Injured Car Accident Victim
Who Pays for Damages In a Florida Traffic Accident When The Driver is On the Job?
4. Medical treatment
It’s important to get medical treatment after you have been injured. That should be your first priority. However, be aware that claims for certain kinds of medical treatment may be disputed.
For instance, where you go for medical care may be an issue. Different kinds of healthcare professionals are treated differently under our personal injury laws. For example, chiropractors may be of great help to your injury, but there may be a limitation on the amount or type of treatment you can receive under certain insurance policies.
Moreover, you may have a time deadline to seek treatment. In a car accident, under Florida’s PIP law, a car accident victim has a 14-day deadline to seek medical treatment.
For details, read our posts about:
Florida Car Accident Compensation Law
Florida Personal Injury Lawsuit Risks
5. Certain damages are not covered under the policy
Insurance policies do not cover every type of harm that can happen in an accident. The sad reality is that accident victims may face losses that will not be covered by the person responsible for their injuries.
For instance, your economic damages may not be covered. These are things like the EMS bill, your doctor’s expenses, and the tab at your local pharmacy. For example, having surgery done on your shoulder after a car accident may have greatly improved your shoulder injury, but an insurance adjuster may argue that the surgery wasn’t necessary.
Other losses, called non-economic damages, may not be covered. These are things that usually don’t have corresponding invoices. The most commonly known non-economic damage is pain and suffering. Also, a victim can collect “loss of enjoyment of life” damages for not being able to attend his or her son’s graduation.
Non-economic damages are just as real to a victim, but insurance companies usually have limits or exclusions regarding these damages.
For more, read: Economic vs Non-Economic Damages
6. High medical bills
Doctors set their fees and hospitals can charge a high price because both are in business to make a profit. Your claim must include all your medical expenses if you want them to be covered by the insurance claim. However, insurance adjusters are not interested in the reasons that your surgeon set his or her rate at a high amount. Insurance companies have their own way of looking at health care charges. Because of this, you may have a huge fight on your hands over whether or not that bill should be paid, and if so, how much will be covered.
For example, one of the most common injuries that arise out of a slip and fall are ankle injuries. These include breaks, sprains, fractures, and even pain. The cost of doctor visits, treatment, and pain medication add up quickly and may be devastating to a victim who is forced to incur these expenses. Knowing how to handle a dispute with an insurance adjuster who is trying to avoid compensating a victim for his or her treatment can make a huge difference to the outcome of the claim itself.
Additionally, insurance companies have comparable charges in your area for the health care services you received. If your claim is much higher than those comparables, expect a challenge to that claim item. Hint: talk to the business office of that physician, clinic or hospital. They may be able to help you deal with the insurance adjuster and get the bill amount respected and paid.
For more, watch:
Why is it so difficult to get a car accident settlement from a car insurance company?
What is the best accident claim advice that I can share?
7. Reasonableness of medical bills
The amount of your medical expenses will be reviewed by the insurance adjuster. So will the procedures that have been coded and billed by the medical provider.
These items will be evaluated to answer questions such as: “Was the charge reasonable for your area?” and “Was the expense reasonable and necessary?”
Insurance companies use sophisticated software programs to analyze accident claims. Not only will the type of procedure be considered for reasonableness, but also the area and location in which it took place. Reasonable fees for a procedure in Miami-Dade County may be much different than in Orlando or in Tampa.
The insurance company may only want to pay what it deems appropriate based upon its own internal company determinations, so you may have a dispute over the reasonableness of the amount charged by your healthcare providers.
For more, see:
8. Insurance Company Bad Faith
Under Florida law, insurance companies are held to a legal duty to act in good faith in the settlement of accident claims. Of course, the reason that the law has imposed this duty upon insurance carriers here in Florida is that they were denying valid accident claims in bad faith just to save the company money.
If you believe that your accident claim was denied wrongfully, then you may have a new legal action to consider. You may have a lawsuit based upon “bad faith” by the insurance company.
Bad faith legal actions are independent of accident claims. They are civil lawsuits filed against the insurance company for an intentional bad act.
For more on bad faith insurance claims, see: Abusive Insurance Adjusters – Leveling The Playing Field
9. Questioning Claims for Back Injury Damages
Often, serious accidents result in back injuries. The human body is vulnerable to spinal cord injuries, as well as injuries to the spine itself, such as herniated discs. Less severe injuries can also be very painful and long-lasting; these are called “soft tissue injuries.”
Unfortunately, insurance companies are skeptical of back injury claims. If your accident claim involves a back injury, then you need to be ready for a dispute over the validity of your claim and the extent of your harm.
a. Did the accident cause the back problem – didn’t show up right away
One common dispute involving accident claims based on back injuries happens when the back injury does not reveal itself at the time of the accident.
The human body is complicated; sometimes, an accident victim may walk away from the accident scene thinking they haven’t been hurt badly. Weeks or even months later, the back injury reveals itself.
When a back injury is delayed onset, it is likely that the insurance adjuster will argue that the accident was not the cause of the harm (also known as “delayed-onset injuries.”)
Medical experts may be needed to provide their explanation in support of your claim. Back surgeons and other health care providers who work with spinal injuries are well versed in insurance company attitudes to back injuries.
For more, read:
Delay in Doctor Visit: Waiting to See a Doctor Can Be Used Against You
b. Causation dispute especially if there is back surgery involved
Another common dispute between accident victims and insurance adjusters in back injury claims involves causation. When there is prior back surgery, then the claim may be dismissed or denied under the argument of “pre-existing condition.”
Again, the opinion of medical experts can be very important here. A past back injury may have nothing to do with the current back injury that was caused by the accident. Your doctor may be able to clarify the distinction and get your claim paid.
Read: Can a Pre-existing Condition Hurt Your Accident Claim?
What Should You Do If You Have A Dispute Over Your Personal Injury Claim?
Attorneys can be very helpful in negotiating with the insurance adjusters simply because most experienced personal injury attorneys can tell you how most insurance companies respond to an injury claim and they can share their past experience in dealing with an individual company or adjuster.
Also, if the victim and the insurance company cannot resolve their differences about causation or the value of a claim, then a victim may be best served by having a personal injury trial lawyer file a lawsuit and present their case to a jury.
A good piece of advice if you have a personal injury claim and are trying to settle the claim on your own, is to speak with an experienced personal injury lawyer before you file a claim to learn about some of the common disputes that can arise with these claims, including the type of evidence needed to prove a claim and the type and amount of damages you can recover. Most personal injury lawyers, like Alan Sackrin, will offer a free initial consultation (over the phone or in person) to answer your questions.
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Do you have questions or comments? Then please feel free to send Alan an email or call him now at (954) 458-8655.
