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Insurance Claims After an Accident: The Basics

One of the first things you should do after being injured in an accident is to file an insurance claim with your insurance provider or the insurer of the person or business responsible. An insurance claim will allow you to receive compensation for any medical expenses, lost wages, or pain and suffering that result from the accident. Below, you'll find explanations of the insurance claims process, how insurance companies calculate the value of a claim, and the differences between first party and third party claims.

First Party Claims vs. Third Party Claims

There are two types of insurance claims: first party claims and third party claims. While a first party claim is one you file with your own insurance company, a third party claim is one you file with the insurance provider of another person or business. Most insurance holders have coverage for third parties who are injured as a result of their actions.

The type of claim you file will depend on who was at fault in the accident, the type of accident that occurred, and the extent of your insurance coverage. For example, if you caused an accident while driving in your car, you should probably file a first party claim with your auto insurance provider. On the other hand, if you were hit by a car while crossing the street or were involved in an accident while a passenger in a car, you should file a third party claim with the driver's auto insurance provider. Alternatively, if you were injured while shopping in a store or eating at a restaurant, you can file a third party claim with the business' insurance company.

The Insurance Claims Process

Whether you were injured in an automobile accident, at a home or building, or while visiting a business, you typically must report the incident to the insurance company within 24 hours of the incident. If you weren't at fault for the accident, you should contact the insurance provider of the business, building owner, or at-fault driver. You'll probably be required to provide information about the cause of the accident and the extent of your injuries.

The insurance company will then open an investigation of your claim. You may be asked to provide photos of the accident scene, the names of any witnesses, or a more detailed account of the incident. In addition, you will probably have to submit to an independent medical examination by a doctor of the insurer's choice. If the injury was caused by a building condition, the claims adjuster may make an inspection of the property.

After calculating the value of your claim, the insurance company will then issue a settlement check. If your claim is denied or if you believe the amount of the settlement is inadequate, you can appeal to the insurance company. An appeal may require you to submit to additional examinations or provide further information and evidence about the accident.

Denial of Claims and the Appeals Process

There are a number of reasons why your claim may be denied. For example, you may have waited too long to file your claim or failed to submit to an independent medical examination. Alternatively, the type of accident you were involved in may not be covered under your insurance plan.

Whatever the case may be, you'll receive notification from the insurance company if your claim is denied. It is then up to you to appeal the denial of claim. Appeals procedures can differ from company to company, so you should take a look at the policy in question to learn about the appropriate next steps. If you have questions about the appeals process or if your appeal is denied, it's probably in your best interests to consult with an insurance attorney.

Calculating the Value of Insurance Claims

While medical expenses and lost wages are usually pretty cut and dried, it's difficult to place a dollar amount on the pain and suffering a person experiences after being injured. Insurance companies have developed damages formulas to calculate how much to pay the injured for these types of non-monetary losses.

The insurance claims analyst first adds up all of your medical expenses. If the injuries aren't too serious, this total is typically multiplied by 1.5 or 2 to determine the amount of your "special damages." However, if the injuries are severe, the total may be multiplied by 5, or even 10 if the injuries are extremely debilitating. Once the special damages amount is determined, the analyst adds your lost wages to determine the amount of your settlement. You can then often negotiate with the insurance company to obtain a higher settlement.

Getting Help

The process of making a claim and possibly seeing it through an appeals process is complicated. If you feel your claim has been denied without reason, you may need legal help. Having an attorney review the facts of your case can put you on the right path to settling your claims, being compensated for your injuries, and moving on.

Next Steps
Contact a qualified personal injury attorney to make sure
your rights are protected.
(e.g., Chicago, IL or 60611)

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