Pace Law

Insurance claims explained: First steps

April 28, 2019

Think of an insurance claim as a journey that must be completed by following all of the necessary and appropriate steps the right way – rather than as something to be done with as quickly as possible. Quite simply, any shortcuts you might be tempted to take could reduce the compensation you should receive for your medical expenses, long term rehabilitation costs, lost income, and pain and suffering. It is essential that you receive fair compensation from the insurer.

The process of categorizing and assessing your injuries, determining the loss of income you have suffered, and evaluating the impact your injuries have had on your life and livelihood involves significant subjective judgments. For that reason, the facts surrounding the accident and your injuries must be presented in detail, and they must be assessed correctly by insurers.

Insurance claims depend on the type of accident that is being reported. However, the basic principles of claim assessment and adjustment are applicable to virtually all other types of insurance claims. Read on to understand how to make a claim.

When do you file an insurance claim?

Personal injury insurance claims are most commonly filed after a motor vehicle accident. However, an injured person may file a claim on their own or the tortfeasor’s (the person whose negligence or omission led to the accident) insurance policy. Think slip and fall, dog bites and pet attacks, cycling accidents, and pedestrian accidents.

Insurance claims and benefits for each of these accidents are different. Before you file a claim, be very mindful of the following considerations. The answers to these questions and considerations will help guide you for what to expect in the insurance claims process:

  • Whether it is a first party or third party claim
  • What is the insurance claims process
  • What particulars of the accident are required
  • What are the time limits for the claim
  • How the value of the claim will be calculated

The insurance claim ‘multiplier’ is often negotiated and can become a contentious element in the claims process. Make sure your multiplier compensates you fairly.

Step 1: Reporting the claim

The first step in filing a claim involves reporting the accident to the insurance company. Ideally, this should be done within 24 hours of the accident, and certainly within a few days of the accident occurrence. In a motor vehicle accident, the claim is typically filed with your own insurance company. If the accident occurs as a result of another party’s negligence, then you will likely file a claim with that party’s insurance company.

Car and motorcycle accident – File a claim with the company of the driver at-fault (and report it to your insurer)

Slip and fall – File a claim with the company insuring the premises for the homeowner, building/property owner, or building/property manager

Pedestrian accident – File a claim against the offending driver’s insurance company

Boating and ATV accidents – Incident to be reported to business owner’s insurance (if the vehicle is rented); against property insurance or specific boat insurer

Pet attack – Report the claim to the pet owner’s insurance company (also possibility of occupiers’ liability)

Medical malpractice – Claim filed with the medical institution’s, hospital’s, and/or doctor’s insurer

The timing involved in filing the claim and the nature of the evidence to be produced are matters requiring careful deliberation. Therefore, it is essential that you speak to experienced insurance claim lawyers. The timing and details involved in filing your claim can set the tone for the claims process and affect the compensation you receive.

Who is the claims adjuster?

The claims adjuster investigates insurance claims. He or she will interview the claimant, the policy holder, and witnesses, review medical evidence, inspect the site, speak to the police and, ultimately, make a determination as to his/her opinion about the insurance company’s liability. The adjuster will also assess the multiplier, if any, which can dramatically increase or reduce your compensation.

Read more about insurance claims

5 ways insurance companies can reduce your settlement

‘Who pays my bills after an accident?’

Are traumatic brain injury victims getting the compensation they deserve?

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Step 2: Information about the accident

Some information about the accident must be provided at the time of making the claim.

Circumstances of accident – This includes the circumstances that led to the accident, as well as the nature and extent of your injuries. Providing photographs of the accident scene, names of witnesses, and other pertinent information will document and help bolster your case.

Medical assessment – It is essential that your injuries are adequately documented and detailed, which is why doctors’ notes, reports from medical assessments and treatments, and receipts for all medical expenses must all be recorded in detail. Don’t worry, not all injuries can be evaluated fully during the early stage of the legal process, and information can be submitted in time. You may also be required to undergo an examination or assessment by a medical practitioner that the insurer chooses.

The claims adjuster or ‘insurance adjuster’ will use all the information he or she can find or uncover about you in determining the value of your claim. Unfortunately, insurers may resort to dubious or underhanded tactics — that may involve invasion of your privacy — in order to obtain information that will reduce your claim. Moreover, it is not unheard of for insurers to overlook, ignore, or discount medical reports or pertinent information regarding the accident that supports and furthers your claim.

Settlement cheque

In a straightforward claims process, the insurance company will assess the claim and issue a settlement cheque. If you feel the amount is inadequate or your claim has been denied, you can appeal to the insurance company.

Step 3: Appealing settlement and denied claims

If you feel the insurance company has failed to adequately compensate you for your injuries and pain and suffering, an appeal may be the proper course of action to remedy that wrong. Filing an appeal is also the method for redressing the denial of your claim.

Contesting the value of the claim – An insurance settlement is aimed at compensating you fairly for the medical expenses you have incurred, any loss of income you may have experienced, and pain and suffering. Every insurance company has its own formulas and protocols in determining the settlement amounts they propose, but it is important to understand that — because there are many subjective elements and criteria involved — the process is not a simple matter of making objective calculations. Companies will apply multipliers that will affect the compensation proposed — such as 1.5 (up to 10, typically) — depending on the severity of your injuries, lost income, and other pertinent factors. If you are not satisfied with the amount of your proposed settlement, you can negotiate with the insurance company.

Denial of claim – A claim can be denied if you filed it too late after the accident, did not submit the report of a recommended medical practitioner, or the insurance company denies its coverage is applicable to your claim. Every company has its own appeals process; in order to navigate that process, you should consult with insurance claim lawyers about your claim and the insurer’s response.

Why insurance claim lawyers

Ensuring that you receive full and fair payment for your injuries and impairments requires that you establish a strong case. Medical evidence, photographs of the accident scene, witness statements, and additional pertinent information will help your insurer determine fault and assess your injuries correctly.

However, the process is also subjective, and m ay involve unexpected departures from a straightforward assessment of your claim. It is not unheard of for relevant medical reports to be ignored or lost in the process; claims adjusters may significantly under-value your claim, and underhanded tactics, such as surveillance, have been employed to undermine or dismiss claims.

Experienced insurance claim lawyers will advocate for you, making sure your claim receives the careful attention and informed assessment it deserves. At Pace Law Firm, we protect our clients from misleading tactics and underhanded methods aimed at discounting the value of their claims.

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Office Location

191 The West Mall, Suite 1100
Toronto, ON M9C 5K8
Phone: 1-877-236-3060
Fax: 416-236-1809