Do Insurance Companies Investigate Injury Claims?

by John Gomez | Last Updated: February 14, 2022

Do Insurance Companies Investigate Injury Claims

After a severe accident caused by another party’s negligence, you may file a claim to pursue compensation for your injuries through the at-fault party’s insurance company. Compensation can pay for relatively minor medical expenses, including an emergency room visit for stitches or a broken bone, or it may include compensation for much more extensive medical costs, for traumatic brain injuries, spinal cord injuries, or multiple broken bones.

Do insurance companies investigate those claims? What do they need to know?

Submitting Your Claim

If you suffered an injury from a car accident or a slip and fall, you should talk to an attorney before submitting a claim to the insurance company. An attorney can help put together a comprehensive claim (often referred to as a “demand”) that includes all relevant information about your injuries and the suffering you have faced as a direct result of your accident.

Your claim will include several pieces of evidence. For instance, your demand to the insurance company may include evidence about how and when the accident took place, as well as a breakdown of your medical bills and records.

The insurance adjuster likely does not have experience in medical care. However, the insurance company will carefully evaluate the medical records and information you provide to determine whether you qualify for an injury claim and what compensation you may deserve.

In many cases, the insurance company will take the information you provide at face value, particularly if you can provide medical records, scans, and testimony from a medical care professional as part of your original claim. However, in some cases, the insurance company may choose to investigate your claim.

Why Would an Insurance Company Investigate an Injury Claim?

Insurance companies may choose to look deeper into injury claims for various reasons. The insurance company may try to protect its interests by establishing that you have not provided accurate, factual information about your accident and injuries. In general, an insurance company will look deeper into claims that involve serious injury, or any claim that they feel does not accurately reflect what happened during the accident.

In some cases, injury claim investigations serve as a vital, necessary part of the insurance claim process.

In the case of minor injury claims, especially those that clearly match the circumstances related to the accident (broken bones from a car accident, for example), an insurance company might conduct only a cursory investigation.

However, after more serious injuries, the insurance company’s standard operating procedure may include an in-depth investigation related to the accident. Many injury claims involve high-value settlements. The insurance company may want to make sure that it has spent its funds fairly: on people who genuinely have the right to a claim due to serious injury, rather than simply handing them out to anyone who claims injury.

An insurance company may want to investigate the person involved in the claim.

In many cases, insurance companies will investigate to better get to know the person involved in the claim. Several red flags could indicate to the insurance company that you have not put together a fair, accurate, and legal claim or assessment of your injuries.

The insurance company may want to know things like:

Whether you have any past injury claims, including claims for severe injuries.
The date and time of any past injuries.
Your prior medical history.

The insurance company may also want to know more about your relationship with the party that caused the accident. For example, if you have a history of causing problems at a store where you suffered a slip and fall, it could serve as a red flag to the insurance company.

Your injuries may require more in-depth investigation if you do not seem to heal normally after your accident.

Sometimes, healing progresses in a relatively straightforward manner. In other cases, you may find that you do not heal as quickly as you might have hoped. Your doctors may have clear reasons for those delays in your recovery. For example, you may have suffered common complications while recovering from serious burns, or you might have had complications from a surgery anticipated to fix a herniated disc.

However, the insurance company wants to know if you might have caused any of those complications yourself, frequently as a result of failing to follow your doctor’s instructions. If you worsened your injuries due to your lack of care, you might end up being liable for those increased medical costs.

Suppose, for example, that you suffer a broken leg in a car accident, and your doctor tells you to stay off the leg completely for 6-8 weeks. Before that time runs out, you attempt to run a marathon with all your friends. Further evaluation from your doctor shows that the leg has healed incorrectly and will require surgical treatment. The insurance company would not bear financial liability for any further treatment costs since your actions worsened your injuries.

Additionally, the insurance company may want to know if you have chosen to self-limit in any way: if you have exaggerated the extent of your injuries, for example. Imagine that you suffered a herniated disc in a car accident. Your doctor lays out a timeline for anticipated healing, either with or without surgery or physical therapy. However, even after going through those procedures, you still have back pain, and you suffer substantial limitations on your usual activities as a result of that pain. The insurance company may want a more thorough investigation into your injuries to determine whether they still, according to medical science, actually cause the limitations that you claim.

Any time your healing does not proceed normally, especially if you ask for compensation for medical expenses related to complications, the insurance company may want to conduct a deeper investigation.

The insurance company may want to conduct a deeper investigation if your injuries or limitations do not line up.

Sometimes, the insurance company may want to know more about your injuries because they do not seem to make sense, according to how your injuries should have occurred.

Suppose, for example, that you slip and fall in a puddle while trying to make your way into a store. The store clearly did not clean up the spill promptly, and therefore bears liability for the accident. When you get up after the accident, you may limp on one side, as clearly shown on the security tapes from the incident.

However, when you file your claim, you claim that you suffered a broken ankle on the other side. The insurance company might want to fully investigate the accident to determine exactly what injuries you sustained and how they occurred, including whether they could have occurred at another time.

Likewise, imagine that your slip and fall occurred as you tried to make your way down a flight of stairs. No one saw you hit your head, and you did not think that you hit your head when asked about the accident immediately afterward. However, later, you started to show signs of traumatic brain injury, and you file a claim that includes compensation for those injuries.

The insurance company might want to conduct a more in-depth investigation to determine when your injuries occurred and make sure they resulted from the fall. The insurance company may also want to know more about the extent of your injuries, including further evaluation of your brain injury and your prognosis.

The insurance company will conduct a deeper investigation if the adjuster has any reason to suspect that you may have exaggerated or manufactured your symptoms.

Sometimes, the insurance company may launch an investigation to determine whether you have lied about or exaggerated any symptoms or injuries related to your accident. Exaggeration can take many forms, especially in personal injury claims. You want to recover as much compensation as possible for any injuries you sustained, so you may want the limitations you have faced and the suffering you have gone through to stand out as part of your personal injury claim.

However, that does not mean you should lie about your symptoms.

For example, if you suffered a back injury in your accident, it could very well cause ongoing pain as you try to move around. You might find that you cannot participate in many activities you usually enjoy. However, back pain might resolve within a few days or weeks of the accident for some people.

Before the claim even has a chance to process, the accident victim may decide to go on a hiking trip with friends or play a sporting match. If that information gets shared with the insurance adjuster while the victim continues to claim ongoing back pain, the insurance company may want to conduct a much more thorough investigation into the injury, including what limitations and pain the victim may still have.

Remember that social media content, including photos you may get tagged in, can also serve as a red flag for many insurance adjusters.

What Does an Injury Investigation Look Like?

An injury investigation may take many forms. The insurance company may want to look at several critical details related to your life after your accident, your injuries, and your claim.

The insurance company may request more access to your medical records.

The insurance company may want to know more about your injuries, according to your doctors and the reports contained in your file. Your medical records will also provide an ongoing report of the treatment you have received, which can make it easier to assess the full extent of any medical bills you may have faced related to the accident.

In some cases, the insurance company might also ask for a statement from your doctors regarding your medical treatment and your prognosis. Your doctor can fill in many details about your injuries and your treatment.

The insurance company may request that you undergo an independent medical evaluation.

In some cases, the insurance company might feel that your doctor has not provided an accurate representation of your injuries. Sometimes, the insurance adjuster may feel that the doctor has exaggerated your injuries or that you have somehow managed to fool the doctor into believing that you have injuries you do not really have. In those cases, the insurance company might request that you undergo an independent medical evaluation.

During an independent medical evaluation, a doctor chosen by the insurance company will conduct tests to determine what weaknesses or limitations you may have. The doctor may conduct tests and scans that your doctor has already performed for the insurance company’s records. The doctor will also assess whether you have actual limitations related to your injuries or self-limit for your own purposes. As an important aside, the insurance company is only entitled to make this request if the case is in litigation (i.e., a lawsuit was filed against the at-fault party).

The insurance company may investigate your activities.

Sometimes, especially if the insurance company has reason to suspect a potentially fraudulent claim, the insurance company may conduct a full investigation into your activities after the accident.

That may mean evaluating your social media activity, including looking for any photos of you or comments you may have made about your activities, as well as hiring an investigator to look into your actual activities. If the insurance company uncovers that you have engaged in activities that your injuries should prevent, it could interfere with your claim.

Injury investigations are very common for insurance claims. Do not take it personally. Many insurance companies use those investigations as a vital part of the process that helps them determine how much compensation an injured party may deserve.

Do you need help navigating an injury investigation or learning more about your rights after a serious injury? Contact an attorney to learn more.

John Gomez

John Gomez founded the firm alone in 2005. Today, John acts as President and Lead Trial Attorney. He has been voted by his peers as a top ten San Diego litigator in three separate fields: Personal Injury, Insurance and Corporate Litigation. Since 2000, he has recovered over $800 million in settlements and verdicts for his clients with more than 160 separate recoveries of one million dollars or more. A prolific trial lawyer, John has tried to jury verdict more than 60 separate cases.

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