Personal injury is a general phrase which describes the type of law governing civil wrongs, or "torts" caused by another, whether a person or entity, such as a corporation. Some of the types of cases which are personal injury cases include automobile accidents, slip-and-falls, product liability, dog bites, boating accidents, medical malpractice, etc. If someone is injured due to the negligence of another person or entity (a "third party"), the injured party (1st party) has a claim against the third party. If the third party has insurance which covers the act of negligence, the insurance company will open a claim, investigate the claim, and decide whether it will accept the claim. Once a claim is accepted, the insurer will proceed to evaluate the worth of the claim. Typically, the persons who perform these tasks are called "insurance adjusters." For an example of a case prosecuted by Ms. Mersch involving a "tort", see [JM Arguello.pdf].
What does it mean for an insurance company to accept my claim?
When an insurance company accepts a claim, it has established two facts: 1) the insurance policy provides coverage for the type of claim made under the policy; and 2) the actual claim is covered under the policy. This is sometimes referred to as "determining coverage." Sometimes the insurer can quickly determine that the type of claim is covered, but it may only be able to determine if the actual claim is covered after an investigation is performed.
For example, if you are injured by another driver, the insurer for the driver (third party) can quickly determine that its insured's automobile liability insurance covers a loss to you up to the limits of the liability coverage. After all, that is why we buy automobile liability insurance. However, if the third party has failed to pay a premium on time causing the policy to lapse, your actual claim may not be covered. No matter what type of third party claim, the insurer will begin its investigation by determining coverage.
Once an insurance company accepts my claim, what happens next?
Once an insurance company accepts a claim, it proceeds to put a monetary value on the claim. To do so, it will gather all medical records and employment records related to any loss of wages as a result of your personal injury. It will then put a value on your pain and suffering, whether physical or mental, as a result of the event leading to the injury (whether an automobile accident, slip and fall, dog bite, etc.). It may also ask you to submit to a recorded statement, which is just that: a statement into a tape recorder in which you respond to questions by an employee or agent of the insurer. The recorded statement seeks information regarding both how the injury occurred and what damages resulted from the event leading to the injury. However, a recorded statement is usually taken at the beginning of an investigation before you (the claimant) have finished treating with a medical provider or before you know the extent of your damages. A recorded statement can also be used to help determine if the actual claim is covered.
What happens if an insurance company does not accept my claim?
If an insurance company does not accept your claim, it must do so in writing and state the reason(s) it has not accepted your claim. If you are not represented by an attorney at the time of the denial of the claim, you may want to seek legal advice at this time. A personal injury attorney will be able to review the insurer's reasons for denial and help you if the attorney believes the denial is without a reasonable basis. Sometimes insurers have valid reasons for denying a claim; other times they do not. Many attorneys who routinely represent injured persons will not charge an "initial consultation" fee. Note that you may have to call more than one attorney to seek assistance, since attorneys may have differing views on the merits of your claim.
If you believe the insurer's denial is wrong, you can file a lawsuit. You can proceed pro se, or on your own, but it is highly recommended that you retain counsel and not represent yourself, if at all possible.
What happens if the person or entity who caused your injuries does not have insurance?
If the person or entity who caused your injuries does not have insurance, you still have a claim against the negligent party. You can proceed to file suit against the negligent party. If you obtain a judgment, you can attempt to collect on the judgment from the negligent party. Generally speaking, however, if a person does not have insurance covering the loss, chances are that you will have difficulty finding assets upon which to execute.
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