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Follow Your Doctor’s Orders: From Diagnosis to the Value of your Injury Claim in NC

May 3, 2017 Brown Moore Personal Injury

If you have a personal injury claim open, one of the areas of the financial recovery that goes into the evaluation of your claim will be medical special damages, which are economic damages. With respect to these economic damages, there is no cap on the amount you may recover. This damage amount must, however, be actual amounts paid, or necessary to be paid, to satisfy the medical billing. For some clients, this may mean out-of-pocket payments made under a deductible or through co-payments. It also means amounts which a client still owes to a medical provider on an open account. In such cases, you want to make sure you recover absolutely everything so that, even if you paid something out of pocket, you are reimbursed for it. The monetary value of your injury claim will depend not only on the receipts you provide but also on other factors.


Not all medical treatment is valued the same, and that is particularly true for insurance adjusters who are looking for any opportunity to deny reimbursement. Generally speaking, there are three primary but broad factors that insurance adjusters consider when determining the value of your injury claim:

  • the medical service(s) or treatment
  • the medical facility and/or medical providers and
  • the extent or length of the medical service(s) or treatment

The Medical Services & Diagnosis

This involves two steps: (1) diagnosis; and (2) treatment. When a personal injury happens, a medical professional must diagnose the injury or condition before appropriate treatment is provided. Oftentimes coming to a diagnosis is relatively quick and simple; therefore, minimal services are required and the billing statement reflects the same.

Sometimes, however, the diagnosis is difficult to uncover. Various tests may be run, different examinations, including x-rays, may be taken. The longer it takes to diagnose, the larger the bill is and the likelier an insurance company will nitpick at the costs. This may not be a problem in most cases so long as the costs to diagnose correspond with the gravity of the diagnosis and the necessity for treatment.

  • The problem: If the diagnosis is relatively small compared to the expense of diagnosis, the adjuster may use a lower multiplier to determine the overall value of damages. The adjuster will try to get away with this by stating that the medical services were not appropriate or even not necessary.
  • The solution: An attorney will investigate and gather evidence that refutes the adjuster’s claim.

The Medical Providers & Medical Facilities

Once a diagnosis is made, you can begin treatment. In today’s age, many patients want alternative methods to heal their injuries. Some believe they work better while others believe they are less toxic to our bodies. Whatever your preference, you should know that it makes a difference with respect to the value of your injury claim.

The insurance industry typically does not look favorably on newer, alternative treatments; they like the traditional methods: M.D.s, medical clinics, and hospitals. They want to see medical records and billing statements from the same doctors, clinics, and hospitals, not medical records from non-physicians, even if the treatment is indeed comparable, or even more productive. The value adjusters place on claims will depend on who and what facilities are used, and that likely means a higher multiplier for traditional methods.

Adjusters are becoming more accepting of physical therapy, and that may be because more and more doctors and hospitals are referring patients to physical therapy. But in that is a key identifier, however: did you go to physical therapy per your doctor’s prescription and referral, or did you choose it independently? In addition to possibly discounting the value of your injury claim due to physical therapy treatment, the following are other professionals and facilities that may result in a similar discount applied by insurance adjusters: chiropractors, acupuncturists, herbalists, massage therapists, naturopathic, and/or, among others, holistic centers.

  • The problem: You may not be able to use whichever treatment and provider you want if you want the full benefit of insurance
  • The solution: An attorney will help you receive the benefits that make you most comfortable so that you can heal the way you want to heal and not the way the insurance company dictates

Extent of Treatment

Some injuries are simple and heal quickly while others are extensive and require a long-term treatment plan while others, yet, are permanent. Generally speaking, the more extensive the injury the longer it takes to heal, and consequently more pain and suffering. The more treatment that is necessitated, the higher the value of your injury claim.

The same logic, however, does not hold true with adjusters if you used non-traditional methods of treatment. For instance, if you received physical therapy for a prolonged period of time, the adjuster may question the necessity of it. They may again attempt to lower the value of your injury claim.

There is nothing, however, that will lower or negate the value of your injury claim more than you, if you do not comply with your medical provider’s treatment plan.

Following the Doctor’s Orders

Let’s say you have been the victim of a personal injury due to the fault of another person, company, or product. You have been to the doctor. You have been given a diagnosis. You have been given a treatment plan. You have been set up with future appointments. And all of this is through traditional physicians and facilities.

Now, let’s say you have been doing the treatment regularly and are starting to feel good. You have an appointment coming up, but also have some personal things to catch up on, so you decided to skip the appointment. You’re feeling good anyway. You continue to feel better and decide that you don’t need treatment anymore.

Little do you know that an insurance company is going to jump on this “gap in treatment” as part of their defense to reduce your injury claim.

One of the favorite arguments that insurance adjusters use to try to settle the claim for less than fair value is the “gap in treatment” argument. An adjuster’s favorite “gotcha” is the “gap in treatment,” and they use it to infer that you, for instance, must not be that hurt, so your compensation will reflect the same.

Our advice: listen to your doctor, and contact an experienced Charlotte, NC personal injury claim attorney to help you get the right value for your injury claim.