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Pushing Back Against Aggressive Insurance Claims Adjusters

Insurance companies are in the business of risk management, which means they go to great lengths to avoid paying more than they have to on a given claim. Claims adjusters are the foot soldiers of this process. They investigate the merits of claims and determine the amount that an insurer will pay. To improve their own performance ratings, some adjusters will use aggressive or even underhanded tactics to reduce their employers’ exposure. People who are faced with disputes with insurers may need to pursue litigation to overcome an adjuster’s strategies.

What does an insurance adjuster do?

A claims adjuster can be thought of as an investigator. They tend to have specific skills that qualify them to review evidence and determine the value that should be paid under the applicable insurance policy. Adjusters do a number of things on behalf of the insurer, including protecting it against fraudulent claims and acting as the insurer’s “eyes and ears” to evaluate the specific facts of the claim. An adjuster will often examine the physical evidence related to a claim, such as damage to an automobile or an individual’s physical injury. They may also conduct interviews with the parties and witnesses. Adjusters may also be directly involved in negotiating settlements with covered individuals, and will also be involved in any litigation that may ensue if the injured person disputes the insurer’s findings. Among other things, an adjuster may be the individual who pressures an injured person to accept a “quick cash” settlement after an accident.

Contesting an adjuster’s conclusions

Ultimately, an insurer has a legal obligation to treat each claim in good faith. Few adjusters will make it easy for an injured person to build a case of bad faith. When an adjuster’s conclusions don’t fit with the facts, the injured person needn’t accept inadequate coverage. Disputing a denied or under-compensated claim doesn’t necessarily require jumping straight to a lawsuit. The first step is often simply to reach out to the adjuster to discuss the rationale for the adjuster’s decision. In some cases, the adjuster may not have a complete set of information, or may have missed an important fact that could change how the insurer handles the case. In any dispute with an insurer, an injured individual who goes without legal assistance will be at a significant disadvantage. An adjuster’s job is to be an insurance expert. The role requires developing a sound basis for the insurer’s decisions. An individual who lacks the adjuster’s sophistication may do more harm than good while making arguments in favor of coverage. An attorney can help the claimant ask the right questions and present evidence in a manner that will give the claim a better chance of being approved. For over 40 years the law firm of Greenman Goldberg Raby Martinez has helped clients in the Las Vegas area recover compensation in personal injury, auto accident, and workers’ compensation cases. If you have been injured please don’t hesitate to reach out to discuss your case with an attorney. Our initial consultations are free. Call us today at 702-388-4476 or contact us through our website.

What to do if an Insurer Denies Your Personal Injury Claim

Insurance companies are in the risk management business. They help their clients manage risk by taking responsibility for keeping costs under control in the event that a claim is made against a policy. In turn, an insurer’s claims adjusters work hard to make sure that claims are valid and not, in the opinion of the adjuster, overbroad or outside the scope of the policy. In some cases, an insurance company takes an aggressive approach, denying claims in hopes that the injured person doesn’t appeal the decision or sue. Fortunately, there are options for people who find themselves in this circumstance.

Insurance companies have a legal obligation to be honest

When someone makes a claim against an insurance policy, the insurer has a legal obligation to conduct an honest assessment of the claim and pay for damages that are covered under the policy. The assessment process needs to be concluded and payments made within a reasonable time. At the same time, insurers also have an obligation to protect their clients, the policyholders, against claims that are invalid, unsupported by the facts, or fraudulent. An insurer that acts in bad faith can be sued. An insurer acts in bad faith if it tries underhanded methods of delaying or avoiding its obligations under a policy. Imposing huge volumes of paperwork, making a lowball offer, or misleading people about a policy question are all examples of potential bad faith. A claim of bad faith may be brought by the policyholder, such as an at-fault driver in an auto accident who is not getting the coverage that a policy promises, or by a beneficiary of the policy, such as someone who has made a claim against the at-fault driver’s policy. Between honest dealing and unambiguous bad faith is a large grey zone where a lot of confusion and conflict can arise. An insurer may in good faith believe that the facts of an injury place it outside the scope of a policy. An adjuster may in good faith review the costs associated with an injury and conclude that they are significantly lower than what the injured person has claimed. A lack of bad faith doesn’t mean that the insurance company escapes responsibility, but it does mean that the injured person may need to take more aggressive steps to protect his or her interests.

Contesting denied claims

When a claim is denied or only partly honored, the beneficiary should consult with an attorney to determine next steps. An insurance company is unlikely to put aside a claims denial without a rigorous consideration of the issues underlying the claim. Those issues may be purely legal, such as a conflict over interpretation of policy language. They may be purely factual, such as questions about how an accident occurred or the extent to which the policyholder is at fault. Or they may involve a mixture of legal and factual issues. The appropriate solution for the problem of a denied claim will depend on the particular policies of the insurer and the nature of the dispute. Some insurers may offer an in-house appeals process to help reduce the risk of litigation. But many insurers will need to be sued to bring them to the negotiating table. Once there, an insurer will have an adversarial position and will need to be countered with strong legal arguments.

GGRM can help you resolve your insurance disputes

For more than 45 years the law firm of Greenman Goldberg Raby Martinez has served clients in the Las Vegas area in personal injury cases. If you are struggling to recover what you are owed in a personal injury claims dispute, contact us today for a free attorney consultation. We may be able to help you reach a better settlement. Call 702-388-4476 or contact us through our website.

Challenges to Suing a Homeowner’s Insurance Policy for Personal Injury

Someone who suffers an injury at a private home may be entitled to coverage under the homeowner’s insurance policy. Insurers are experts at denying claims and will frequently look for reasons why an injury did not qualify under the homeowner’s insurance policy. Policies are written to provide insurers with numerous ways of escaping liability. As a consequence the insurer may need to be sued, often along with the homeowner. In doing so the injured plaintiff can face a number of challenges. Here are two examples.

Coverage limits may not fully compensate the plaintiff

The first challenge can simply be the coverage limits built into the policy. It should be no surprise that a homeowner’s policy is deliberately designed to limit the financial exposure of the insurer to risk. Policies do this in part by placing strict caps on how much the insurer will pay out for different events. The details of these caps can draw fine distinctions between who qualifies for coverage, how much coverage will be given to specific types of injuries, and so on. A policy will always specify how much the insurer will pay for a given injury (normally some factor of $100,000). Many policies include “umbrella” provisions that add an extra catch-all value on top of the itemized coverage. The insurer will not pay more than the maximum amount of coverage. The first challenge for plaintiffs is often that the amount available under the homeowner’s policy is simply not enough to cover all the costs associated with an injury. A policy with a coverage limit of $100,000 per incident and a $500,000 umbrella provision will not make a plaintiff whole if the plaintiff is facing $1 million in damages.

Plaintiffs may not be covered in some situations

A second challenge can arise if the plaintiff is not within the scope of coverage. Some policies may distinguish between full-time residents, guests, and contractors. It may also disclaim responsibility for specific types of injury. As a hypothetical example, a policy might specify that the insurer does not cover accidental electrocution of someone who is working on electrical systems without the appropriate professional license. One area where this “category” problem can be important is cases where the injured person was performing services for the homeowner at the time of the injury. Many homeowners’ insurance policies disclaim responsibility for injuries to contractors, with the idea being that the contractors will already have their own insurance. If a neighbor is injured while helping a landowner clear brush, the insurer may look for ways to characterize the neighbor as a contractor. One way it might succeed in doing that is if the neighbor was being compensated in some way for the work. For example, if the neighbor is helping out as a way to repay the landowner for lending the neighbor a tractor, that might be enough to place the neighbor outside the coverage scope.

GGRM is a Las Vegas personal injury law firm

Being injured at another person’s home raises a lot of difficult questions, not least of which can be how to preserve the relationship with the homeowner despite being in a legal dispute. For more than 45 years the law firm of Greenman Goldberg Raby Martinez has helped injured clients recover compensation. We work with clients to examine the complete picture of each case to ensure that the client’s personal and financial interests are protected. Call us today for a free attorney consultation at 702-388-4476 or reach us through our contact page.

Should Injured Workers Bring an Attorney to their Medical Exams?

After being injured at work it’s important to follow the steps for filing a workers’ compensation claim. Ideally an employer’s workers’ comp insurer will pick up the costs of the employee’s medical care from the first visit to a doctor until the injury has healed. In reality, though, insurers work hard to limit their exposure to costs related to covered injuries. One way they try to do this is by arguing that the injury is not as significant as the employee claims. This risk can be mitigated by having an attorney present during medical exams. After receiving a claim for benefits an insurer has the right to require the injured worker to submit to an independent medical examination, or IME. The formal purpose of the IME is to ensure that the insurer is basing its coverage decisions on a reliable and supposedly neutral diagnosis by a physician other than one with which the patient may already have a relationship. In reality insurers often request an IME because they disagree with an initial diagnosis, or have doubts about whether an injury is related to the worker’s job. The state maintains an official list of physicians who are authorized to perform examinations of work-related injuries. Insurers are very familiar with the doctors on this list. They know who has a history of providing insurer-favorable diagnoses and will steer unwary patients to those doctors whenever possible. When a worker is told to attend an IME, the insurer may provide a limited list of doctors to choose from for the examination. The worker is required to attend the IME, but has the right to request a second opinion from another state-approved doctor if the outcome of that initial exam is not satisfactory. The IME is potentially one of many “independent” examinations that the patient will undergo over the course of a workers’ comp claim. For example, if the injury results in a permanent partial disability the extent of the disability will need to be evaluated by a physician who is specifically trained in how to do this. The extent to which a patient needs to have an attorney present at a medical exam will depend on the nature of the injury and the extent to which facts about the injury are in dispute. An attorney can help the patient decide whether having an attorney or other witness on-hand is advisable, but as a general rule it is better to have a witness along than to go alone. The witness can take notes about the examination and may provide important testimony in the event that the results of the exam need to be disputed in a later proceeding. Note that some physicians may claim to have a rule prohibiting others from attending these exams. This should raise concerns that the exam may not be fair, and should be disputed. For more than 45 years the law firm of Greenman Goldberg Raby Martinez has helped injured workers get the coverage they deserve. If you have been injured at work, our experienced injury attorneys are standing by to offer advice about your case. Call us today for a free attorney consultation at 702-388-4476 or reach us through our contact page.

Filing Complaints with the Nevada Division of Insurance

Filing Complaints with the Nevada Division of Insurance
From a certain point of view, insurers are in the business of denying claims. Finding a way to limit the scope of benefits a claimant can receive is how insurance adjusters make their living. Naturally, an insurer is legally permitted to aggressively defend itself against the possibility of fraud or inflated damages claims. But an insurer’s aggressive posture can and often does cross the line into the realm of bad faith or, even worse, fraud on the part of the insurer. When an insurance dispute arises the insured has the option of submitting a complaint to the Nevada Division of Insurance.

What does the Nevada Division of Insurance do?

The Division of Insurance has a number of important functions, with consumer protection being among time. The Division has staff dedicated to helping resolve disputes between consumers and insurers. They will investigate cases and offer mediation services to bring the dispute to amicable resolution without involving the relatively slow and expensive court system. The Division oversees state licensing of insurance professionals, which means that it has the authority to revoke the license of a professional or even a business if it has committed serious violations. The complaint process begins by submitting a form online, or alternatively by mail. A consumer must provide all the information the Division needs to evaluate the claim, including a signed release form to permit the Division to seek medical information from the claimant’s doctors, if necessary. The Division considers cases involving potentially improper denials of claims, improper cancellations of policies, and disputes related to the necessity or efficacy of medical treatments. Once the Division receives the complaint and provides a notice to the insurer, the insurer has a short time to respond to the complaint.

The Division of Insurance has limited power to resolve disputes

Although the Division can help a consumer in a number of important ways, its authority in disputes is limited to a mediator role. Among other things, it cannot handle complaints brought by consumers who are represented by an attorney. Essentially, the Division offers no-cost assistance to consumers who otherwise cannot find or afford the help of an attorney. The Division also cannot order an insurer to provide coverage or alter a decision. A consumer who feels that an insurance company is acting in bad faith or unethically may find that pursuing recourse through litigation offers a greater chance of a favorable outcome. This is especially true when a case involves complicated issues that make it difficult to compile a comprehensive complaint without an attorney’s help. Speaking to an attorney needn’t foreclose submitting a complaint to the Division of Insurance. The consumer can’t be represented by an attorney in a matter that is submitted to the Division, but an attorney may be able to help the consumer determine whether it makes sense to pursue a remedy through the Division complaint process or through litigation.

GGRM is a Las Vegas personal injury law firm

For more than 45 years the law firm of Greenman Goldberg Raby Martinez has represented injured clients in cases involving personal injury, workers’ compensation, and insurance disputes. If you aren’t sure whether filing a complaint with the Division of Insurance is the right move for you, call us today for a free attorney consultation at 702-388-4476 or reach us through our contact page.