How Insurance Companies Evaluate Personal Injury Claims

Understanding how insurance adjusters evaluate personal injury claims helps you know what they're looking for and how to strengthen your case. Insurance companies use specific formulas and factors to determine settlement offers.

Insurance adjusters work for the insurance company, not for you. Their primary goal is to minimize payouts while resolving claims. They evaluate your claim by:

• Reviewing liability (who was at fault)
• Assessing the severity of injuries
• Calculating economic damages
• Estimating non-economic damages
• Determining risk if the case goes to trial

Understanding their process helps you present your case more effectively.

When their insured is obviously at fault (rear-end collision, running a red light), adjusters offer more because they know they'll likely lose in court.

If fault is questionable or shared, offers drop significantly. Comparative negligence states reduce your recovery by your percentage of fault.

Police reports, witness statements, photos, and video footage strengthen your claim. Weak evidence gives adjusters room to dispute fault.

The adjuster asks: "How likely are we to win if this goes to trial?" The lower their chances, the higher your settlement value.

• Emergency room visits carry more weight than urgent care
• Hospitalization and surgery indicate serious injuries
• Specialist care (neurologists, orthopedists) adds credibility
• Physical therapy shows ongoing treatment needs
• Chiropractic care alone may be viewed skeptically

• Immediate medical attention after the accident is crucial
• Gaps in treatment suggest injuries aren't serious
• Consistent follow-up care demonstrates ongoing problems
• Treatment duration (weeks vs. months) affects value

• Higher bills generally mean higher settlements
• Adjusters scrutinize whether treatment was necessary
• Bills must be related to the accident
• Future medical costs increase settlement value

The adjuster asks: "Are the injuries legitimate and well-documented?"

• Broken bones
• Herniated discs visible on MRI
• Surgical procedures
• Permanent scarring
• Traumatic brain injuries with imaging

These injuries are difficult to dispute and command higher settlements.

• Whiplash
• Soft tissue damage
• Sprains and strains
• Pain without visible imaging evidence

These injuries are easier for adjusters to minimize, resulting in lower offers.

• Temporary injuries that heal completely are worth less
• Permanent disability, chronic pain, or lasting limitations significantly increase value
• Future medical needs add to settlement amounts

Documented time off work with pay stubs showing lost income.

If you can't return to work or must take a lower-paying job, this is calculated based on your age, career, and life expectancy.

Permanent injuries that reduce your ability to earn money over your lifetime significantly increase claim value.

Adjusters verify wage loss with:

• Pay stubs
• Tax returns
• Employer statements
• Time sheets

This is the most subjective and negotiable part of your claim. Adjusters use several methods:

• Take total medical bills and multiply by 1.5 to 5
• Minor injuries: 1.5-2x
• Moderate injuries: 2-3x
• Serious injuries: 3-5x
• The multiplier depends on injury severity, permanence, and impact on life

• Assign a daily dollar amount to your pain
• Multiply by the number of days you've suffered
• Less commonly used

• Permanent scarring or disfigurement
• Chronic pain
• Impact on daily activities and quality of life
• Emotional distress, anxiety, or depression
• Loss of enjoyment of life

If the at-fault party has $50,000 in liability coverage and your damages are $200,000, you can only recover up to the policy limits (unless you have underinsured motorist coverage).

Adjusters may offer policy limits quickly for serious injuries when coverage is insufficient.

Some defendants have additional coverage beyond standard auto or homeowner's policies.

Adjusters evaluate whether you're truthful and sympathetic:

• Consistent statements about how the accident happened
• Medical records that match your complaints
• Following doctor's treatment plans
• Honest about pre-existing conditions
• Professional demeanor

• Exaggerating injuries
• Social media posts contradicting injury claims
• History of prior injury claims
• Inconsistent statements
• Gaps in treatment suggesting malingering

Studies show represented claimants receive 3-4 times more than unrepresented ones, even after attorney fees.

• Insurance companies know lawyers will file lawsuits
• Lawyers understand claim valuation
• Attorneys gather stronger evidence
• Legal representation signals you're serious

They know most people don't understand claim value and will accept lowball offers.

• Urban juries tend to award more than rural juries
• Some counties are known as "plaintiff-friendly"
• State laws vary on damage caps and comparative fault

• Pure comparative negligence states vs. modified comparative negligence
• States with damage caps on non-economic damages
• Statutes of limitations and filing deadlines

• Defense attorney fees
• Expert witness costs
• Court costs
• Time investment

• Strong plaintiff cases increase settlement value
• Weak defense positions motivate higher offers
• Sympathetic plaintiffs (children, elderly, severely injured) are riskier to defend

Adjusters weigh the cost of settlement against the cost and risk of trial.

Medical bills: $25,000 Lost wages: $5,000 Property damage: $3,000 Total economic damages: $33,000

Pain and suffering: $25,000 x 3 (multiplier for moderate injury) = $75,000

Total claim value: $108,000

The insurance company might offer 60-75% of this initially ($65,000-$80,000), expecting negotiation.

Hoping you'll accept before understanding your claim's value.

Claiming treatment was unnecessary or excessive.

Arguing your current problems are from old injuries.

Asking leading questions to get you to minimize injuries or admit fault.

Hoping you'll get desperate and accept less.

Even if untrue, to reduce their payout.

Creating bureaucratic obstacles.

Document injuries right away.

Gaps hurt your credibility.

Photos, witness information, medical records, lost wage proof.

Especially without attorney guidance.

Don't accept the first offer or settle before treatment ends.

They know how to present your case for maximum value.

Document daily symptoms and limitations.

Nothing on Facebook, Instagram, or other platforms about the accident or your activities.

• Offer comes within days of the accident
• Offer is less than your medical bills alone
• Adjuster pressures you to settle quickly
• They won't explain how they calculated the offer
• Offer doesn't account for future medical needs
• They claim "this is our final offer" early in negotiations

Reject and counter when:

• The offer doesn't cover all your medical bills and lost wages
• Pain and suffering compensation seems inadequate
• You haven't finished medical treatment
• The adjuster used a low multiplier without justification
• Your attorney advises the offer is below fair value

Accept when:

• The offer adequately compensates all damages
• Your attorney recommends it as fair
• Further negotiation is unlikely to yield significantly more
• You want to avoid litigation time and uncertainty

Insurance adjusters use specific formulas and tactics designed to minimize what they pay you. Without understanding how they calculate settlement offers, you're negotiating blind.

An experienced personal injury attorney knows exactly how insurance companies evaluate claims and can present your case for maximum value. Dear Legal can connect you with lawyers who regularly negotiate with insurance companies and understand how to counter their tactics.

Answer a few questions about your injury, and we'll match you with qualified personal injury attorneys in your area who offer free consultations. Find out what your claim is actually worth, not just what the insurance company wants to pay.