What Is Considered by and Insurance Adjustor?
Written by Editor   
Wednesday, December 10, 2014 01:56 PM

What are some of the things that an insurance adjuster or claim representative will consider in considering a case?

On December 9, 2014, the Fourteenth Court of Appeals upheld a decision on appeal from the 11th District Court in Harris County Texas.  From this Appeals Court Decision several interesting points emerge that contribute to an answer of this question:

“Allstate claims that [a provider] solicited referrals from attorneys … . [and] would treat the injured parties under a ‘letter of protection’ …. that [the provider] would seek to recover payment of its bills from its patients only if there were a recovery reached by way of a settlement or judgment; that is, the patients were released from financial responsibility for health care services if there was no settlement or judgment with an insurer."

“Allstate sued …. [and] asserted that had it ‘been made aware of these methods and practices, it would not have considered such billings in settling the claims.’ … Allstate filed suit in December 2009, seeking to recover the sums it paid for services for which patients were released from liability and which it claims were [improper]."

“Allstate … offered the 2010 affidavit of Aaron Patterson, SIU (‘special investigation unit’) analyst for Allstate, …. He stated if a patient is released from any financial responsibility, the amounts of health care charges would not be included in a bodily injury settlement offer. … Patterson outlined the factors which claims adjusters take into account in determining what offer to extend in settlement.  Those included liability facts, property damage of the insured party’s vehicle, the actual injury of the party, medical bills, pre-existing conditions, medical conditions, loss of earnings, extent of medical treatment, and the adjuster’s independent judgment.  The claims representatives also utilized computer tools, such as Colossus and the Mitchell Expert Claim Summary ('Mitchell’).  Patterson explained that Colossus helps the claims adjuster determine the overall value of a claim, the amount of damages, medical bills, pre-existing conditions, and medical offsets where multiple claims are involved.  Mitchell, a computer audit system, reviews the amount of actual charges input into the system.  In making their decisions, the claims representatives or adjusters do not rely solely on Colossus and Mitchell.  Rather, they maintain and utilize independent judgment in assessing each claim."

From this we see that Allstate considers a letter of protection that releases the patient from any financial responsibility unless the case is settled to be a questionable practice.  We see that Allstate would be unwilling to consider such claims, presumably because if the patient was not financially liable then neither would their insurance company.  We see that Allstate (in 2010) used claim valuing software and/or claim auditing software in making their decisions. We see that "claims representatives or adjusters do not rely solely on Colossus and Mitchell.  Rather, they maintain and utilize independent judgment in assessing each claim.” And we see that liability facts, property damage of the insured party’s vehicle, the actual injury of the party, medical bills, pre-existing conditions, medical conditions, loss of earnings, extent of medical treatment, are considered when determining the settlement of a claim.


Source:  Allstate LOP Fraud Word.docx