Five Key Reasons Why Insurance Companies Deny Personal Injury Claims.
Maryland Insurance companies deny hundreds of claims each week. I’ve identified, perhaps, the five principal reason insurance companies use to deny claims concerns citing their oft-raised contention that “there is no personal injury sufficient to justify monetary compensation resulting from most motor-vehicle accident occurring in Baltimore, MD”. Let’s look at what we hear from insurers, and how we defeat it.
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- There was not enough property damage to the involved vehicles for any the occupants to have been hurt.
- Their injury was really not related to that after all, but rather related to arthritis or a degenerative process at work in someone’s body.
- Their insured did not cause the accident.
- The Plaintiff was contributorily negligent.
- The injuries involved are “merely soft tissue”.
There was not enough property damage to the involved vehicles for any the occupants to have been hurt.
This is nonsensical in many ways, as there is no medical or scientific support for this position, i.e. that their is a connection between observable property damage and the likelihood or severity of injury.
However it does have some common sense appeal. And indeed, insurance companies have been extraordinarily successful in selling this argument to judges and juries over the course of the last 20 to 30 years.
Insurance companies will frequently point to an alleged pre-existing or underlying condition as a reason to deny a claim. The argument here is that, although someone may have sustained trauma as a result of a motor vehicle accident
Their injury was really not related to that after all, but rather related to arthritis or a degenerative process at work in someone’s body.
This can be also seen as nonsensical in many regards. Everyone of a certain age is going to have degenerative changes in their joints and their body, generally. I’ve had countless clients over the years how have had their claims denied based on this contention ask me: “If this was all pre-existing, why did it not hurt before”. I have always found this to be a great questions, posed by someone, suffering with pain they did not have before an accident, who is confused, perplexed, and likely angered by an insurance claims adjuster they have never met, contending this they actually, perhaps secretly, had the conditions all along.
Medical evidence is complex, and medical findings are subject to multiple interpretations. It is easy for an insurance company to find a doctor who will say “Ah ha”, this person’s pain complaints come not from an accident, but rather because of degenerative changes in the affected body part -in his or her opinion.And the insurance company does find these doctors, who are most often skilled and seasoned professionals, who render competent, believable opinions.
Their insured did not cause the accident.
Of course an insurance company may always deny a claim by saying or contending that their insured did not cause the accident – the plaintiff did. The Plaintiff always carries the burden of proof, and part of that burden is to show the other, at-fault party, caused the loss.
The Plaintiff was contributorily negligent.
We often see a related denial. Of course an insurance company may always deny a claim in a contributory negligence jurisdiction, such as Maryland, by saying or contending that their insured did not cause the accident – the plaintiff did. Maryland law recognizes the archaic doctrine of contributory negligence which prohibits a plaintiff, who contributed to the happening of an event in even the slightest manner, from any recovery whatsoever. Where the insurance company asserts that injured person was contributory negligent, and therefore not entitled to recover, or where there is a factual dispute regarding the causation of a motor vehicle accident these matters typically must be resolved in court by trial.
Some insurance companies are known to deny claims, or make an offer that is so unreasonably low as to have the same effect as a denial, on the basis that:
The injuries involved are “merely soft tissue”.
“Soft tissue” in this context is an insurance company code phrase, meaning:
- not hurt
- not injured, or
- not believed.
The argument here is that the injuries are not broken bones, or severe lacerations, but rather injuries to the muscles, ligaments, and tendons and therefore, are not serious, and that a person that sustained them should not be appropriately compensated.
From an insurance company’s perspective, a soft-tissue injury is “damage” to the body’s non-bony structures, such as muscles, ligaments, and tendons. I say “damage” reservedly, as, in my estimation, if a claims adjuster is calling my client’s injures “soft-tissue” that means that adjuster has taken the position my client does not have an injury that should be taken seriously. These are distinct from orthopedic injuries like fractures, which are easily verified through objective diagnostic tools like X-rays. Common examples of soft-tissue injuries in insurance claims include sprains (ligament damage), strains (muscle or tendon damage), contusions (bruises), and whiplash, which involves the rapid extension and flexion of the neck.
It is perhaps the lack of objectivity that leads Insurance companies to view “soft-tissue” claims with a specific lens of scrutiny primarily due to the subjective nature of the evidence. While a broken bone presents clear, objective proof of injury, the primary evidence for a soft-tissue injury is often the claimant’s own report of pain, stiffness, and limited motion. This subjectivity, in theory, makes it more challenging for an adjuster to quantify the injury’s severity and its impact on the individual’s life. Because they are not easily visible on X-rays, insurers question the existence or severity of the injury, sometimes, as least at a time, classifying them under internal programs like “MIST” (Minor Impact, Soft Tissue) which can trigger lower settlement offers. When evaluating an injury claim, an insurance adjuster may well consider several key factors to establish causation and value. The problem is indeed subjectivity, but the other way. It is the insurance adjuster deciding, without evidence, the injuries are “soft tissue [read: minor or non-existent] and not serious.
The mechanism of injury is often critical; for instance, a low-speed rear-end collision might be deemed insufficient to cause the severe whiplash being claimed. The timeline and consistency of medical treatment are heavily weighted. A delay in seeking medical attention or gaps in treatment can be used by an insurer to argue that the injury was not serious or was caused by an intervening event. Any hole in an injured Baltimore motorist’s claim that can be exploited, will be exploited by the zealous claims analyst.
Furthermore, the credibility of the claimant is paramount. Adjusters will scrutinize medical records for consistency in the reporting of symptoms. They will look for detailed notes from healthcare providers that document objective findings like muscle spasms, swelling, or a reduced range of motion. Thorough documentation is the cornerstone of a credible soft-tissue claim. This includes not just diagnostic reports like MRIs (which can sometimes show tears or inflammation), but also physical therapy notes, physician narratives, and records of prescribed medications.
It comes as no surprise, insurers also investigate for pre-existing conditions. If a claimant has a history of back problems, the company may argue that the current symptoms are an exacerbation of a prior issue rather than a new injury caused by the incident in question, thereby reducing their liability. Ultimately, while insurers recognize that soft-tissue injuries are legitimate and can be debilitating, they approach these claims with a rigorous verification process, demanding substantial and consistent evidence to justify a settlement
Insurance companies have valid reasons for denying claim. I’m not suggesting they don’t. For example if they can prove fraud, and the person is feigning injury or has staged an accident, clearly that claim is appropriately denied. In my practice, we don’t handle fraud claims. Likewise, if an insured person does not cooperate with his or her insurance company, then the insurance company is well justified in denying coverage, and therefore, the claim the injured person has brought.
I’ve prosecuted thousands of personal injury claims over the years. While I certainly cannot say I’ve seen every reason that an insurance company might use to deny a claim – I’ve certainly seen a lot of them. I invite all potential clients to participate in a no-cost analysis and strategy conference. Contact me today to arrange a time to meet. 410 591 2835, or simply complete the form at the bottom of this page.
- Baltimore Personal Injury Trial Lawyer Eric T. Kirk
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For over three decades, I have battled against the nation’s largest insurance companies, always endeavoring to ensure my clients receive the compensation they deserve. As lead counsel in thousands of cases across Maryland, New York, and Florida, I have recovered millions for clients whose claims were wrongfully denied and delayed. Whether denying fair compensation for a personal injury victim or denying benefits to a homeowner, Insurance companies employ policy exclusions, technicalities, and lowball offers to deny and defeat claims. They also hire very good lawyers to fight you in court. So should you. When an insurance company unfairly rejects a claim, I stop them.
