Insurance Claim Denied


Below is an exchange between William D. Keefe, a Massachusetts personal injury lawyer, and an insurance adjuster regarding whether or not you need a lawyer to represent you after a car accident. The entire exchange is copied in its entirety with screen captures posted at the bottom.

What is the best way to handle an automobile accident yourself without using an attorney and dealing with the insurance adjuster directly?

CB, Retired – Insurance Claims

Some facts first:

  1. Attorneys receive 30 -50% of any settlement or legal judgment.
  2. In most cases, the amount of the additional settlement or judgment obtained is much less than the fees the attorney collects.

The vast majority of insurance adjusters know what a claim is worth. Most attorneys know what a claim is worth. The problem comes into the mix in the form of attorney commercials which imply that adjusters are out to screw over an insured or a claimant or promise that the attorney can somehow deliver a huge wind fall to an injured party.

No adjuster wants to keep a claim active any longer than necessary. The vast majority of offers made are based on real adjudicated cases.

A sure way to obtain fair and reasonable treatment is to be honest with the adjuster. We know fraud and an inflated claim when we see it.

As an interesting note. Many insurers offer what it referred to as an “open ended release. (settlement)” It provides reimbursement of all documented out of pocket losses (expenses) , a sum for “pain and suffering” and a promise that the insurer will pay all related medical bills incurred during a fixed future time frame (usually the next six months). I offered such releases in several hundred claims over the years. Well over a hundred claimants accepted the offer. I can recall only two cases where a claimant presented additional medical bills. One claimant received treatment for an addition 45 days. I immediately paid the total presented by the claimant as he presented the bills. One claimant submitted a bill for his annual physical examination which his employer had already paid for. I denied payment. His words were something along the lines of “well, you can’t blame me for trying, can you”.

William Keefe, Esq.

This answer is completely wrong.

An insurance adjuster may KNOW what a claim is worth, but they will never OFFER a fair value to someone who is not a lawyer. Why? Because why would they?

As I wrote on a similar post:

There is no good way to get a settlement from a car accident without a lawyer.

If you do not have a lawyer then the claims adjuster will assume you do not know the value of your claim and will make you a lowball offer. When you try to negotiate they will simply tell you that they have settled 1000s of cases just like yours and know this is how much it is worth. If you persist, they will tell you that they have had 1000s of cases just like yours go to trial and know that a jury will give you less.

What if you are still not willing to accept the offer? They have no obligation to keep negotiating so they will not offer anything else and tell you to take it or leave it.

So what do you do then? Do you file a lawsuit on your own without a lawyer? Then the claims adjuster will happily wait for their lawyer to either beat you up in discovery or wait for you to make a mistake by either missing a statute of limitations or a deadline imposed on your by the rules of civil procedure. Either way, they have no incentive to offer you anything close to the value of your claim.

You may be thinking that you are saving money by not paying for a lawyer, but generally speaking a lawyer pays for himself in the value he or she will add to your claim.

Several years ago I had a client meet me two weeks after an accident. The claims adjuster for the insurance company had been calling him every other day trying to get him to sign a release for $800. The client even came in with a copy of the release that was emailed to him.

Several months later that same case settled for $20,000.

The insurance company was never going to offer him $20,000 while he was unrepresented.



I dealt with ambulance chasers like you for many years. You and those like you make claims grow exponentially not because of real injuries but by using doctors who fabricate and exaggerate alleged injuries. You get a percentage of the take which means that you have a vested interest in the fraud you promote.

Yes, every adjuster attempts a “first call” settlement. Most claimants would not visit a doctor except for the fact that some attorney refers them to a doctor who they have a financial relationship with.

I paid what the claim was worth at the time I attempted settlement based on the evidence presented. It made no difference if some attorney was involved or not.

Its people like you who spend billions each year on misleading TV ads to scam the system and run up insurance rates.

William Keefe, Esq.

So many problems with this response, Carl, but I’ll try to address them.

First, thank you for adding to my point. As an insurance adjuster you never meet with the injured person and you never get to know them or what they are dealing with. As such, when you are presented with a claim you take a cynical view and assume everyone is lying to you. You therefore make a lowball offer hoping this “fraud” will go away. The fact that you believe every lawyer is an ambulance chaser and every claimant is a fraud IS WHY a person needs to hire a lawyer. They will never get a fair offer from you because you are prejudiced into believing they are fabricating or exaggerating their injuries.

Second, where exactly, besides your own biases, are you getting the idea that an injured person will not see a doctor unless an attorney tells them too? A) Virtually all (if not all, but I’m not going to check) of the clients I have ever represented have already been treated by i) ambulance, ii) emergency room, iii) primary care physician, or all three before I ever receive a phone call. I’m not sending anyone anywhere. B) I don’t have a financial relationship with any doctors. You might be suggesting that the doctor gives a lawyer some sort or kickback or something, but that doesn’t happen. The rules of professional conduct would prohibit such an arrangement. C) If someone is injured they are going to go see a doctor. Again, you assuming a person with a broken arm only went to the hospital or to an orthopedic doctor because an attorney told him to is clear evidence that you will not evaluate his claim fairly.

Third, you claim that you paid what the claim was worth at the time. I love the language you use: “I paid.” That sounds right since every adjuster I speak to acts like the money is coming out of their own pocket. Additionally, you would know that there is no way to adequately assess the value of the claim so early on in treatment. And yet, you defend your position of trying to force a settlement two weeks after an accident and while the injured party is still treating by stating that your offer is based on the only evidence available at the time – before the party has even received his first medical bill. Also, I find it telling that this is such a common practice that you even have a name for it: “first call” settlement. Again, this is why hiring an attorney is almost necessary because they will be able to gather the evidence and present it to the insurance company rather than leaving it up to the adjuster to base his or her decision on whatever evidence they claim to have looked at.

Fourth, representing an injured party and making sure he gets a fair compensation for his injuries is not “scamming the system.” That is literally what the system is designed to do. If someone’s negligence causes injury then that person is responsible for the damages he caused. There is nothing unfair or devious about having the negligent party or his insurance company pay for the damages he is required by law to pay.

Finally, your rant proves you have been drinking the company Kool-Aid for too long. Numerous studies have evaluated the impact of tort reform on insurance rates and premiums and found that it does nothing. Insurance rates and premiums still go up. High insurance rates are caused by corporate greed, not because a car accident victim asked for their hospital bills to be paid after they were rear-ended by someone who was too busy texting on their phone to pay attention to their driving.

If you have been involved in an accident, you can either hope that the insurance adjuster will believe you and make you a fair offer, or you can consult with an experienced personal injury attorney who will work hard to make sure they fairly evaluate your claim and give you the money you deserve.

If you’ve been involved in a car accident and with to speak to an attorney, contact me for a free consultation at 978-852-0914, or via email at will@wdklawfirm.com.


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