Those who have spent time reviewing claims have most likely had many head-scratching moments. How did the adjuster come up with that liability assessment? How could the insurer possibly have paid so much on this claim? How could we have ever let this one go to litigation? It's often a game of Monday morning quarterbacking, second guessing the “he said, she said” of who struck John scenarios.

Perhaps the biggest head scratcher of them all is a low-impact claim with allegations of soft tissue injuries. While not claiming that this is out of the realm of possibility, these are cases that always warrant a thorough and detailed investigation. According to the Department of Transportation, 80% of all accidents occur at less than 20 miles per hour. Knowing this, it is imperative that claims organizations have a successful low impact strategy in place.

Don't assume it is fraud just because there is no property damage. Rather, recognize that impact can have a causal relationship on injuries, and lack thereof may be indicative of opportunistic fraud. Insurance Research Council statistics suggest that more than one-third of all accidents involve this type of fraud, which is a little different than outright fraud, such as staged accidents. The difference is that with opportunistic fraud, the loss really did occur but an involved party is trying to get more than he or she is entitled to.

By following a simple 10-step plan, carriers will be able to sort through the facts, conduct more consistent investigations and achieve more accurate outcomes.

1) Triage claims at the outset of the loss. Focus on key elements of the property damage, such as damage to any sheet metal and drivability. Gather information from all involved parties to understand early on if there was meaningful property damage.

2) Get the right claim to the right person. Let's face it, not all claims are the same and at times it is beneficial to have a specific workgroup with niche expertise and local claims knowledge, as well as a proficiency in both material damage and medical claims adjusting.

3) Obtain a recorded statement of all claim parties, including occupants and witnesses. Ask critical questions about events leading up to, during and after the accident. Establishing a mechanism for injury is crucial. If possible, meet the parties involved in person so as to assess credibility. Key aspects of the claimant statement should include:

  1. Facts of loss
  2. Scene description
  3. Other party description
  4. Medical provider description/directions/procedures.

4) Physically inspect all claim vehicles involved in the accident. Identify the principle direction of force. Observe force lines, abrasions and metal folds. Check for multiple impacts and old damage. Consider the vehicle movement at impact and compare to what was said in the claimant statements. Was the vehicle stopped or moving? Did the front end dip from braking? Is the damage consistent with speed? Does the damage match the striking object? Are there appropriate pain transfers?

5) Take photographs. A cornerstone of a good low impact investigation must include photos of both vehicles, as it is possible to have significant damage to one car and virtually none to the other. For example, a Ford Focus that rear-ended a full-size Chevy pickup would under ride the truck, resulting in extensive front-end damage to the Ford and virtually no rear-end damage to the Chevy.

Each vehicle should be photographed from multiple angles at a distance that can capture the entire vehicle. Both involved vehicles should be photographed from the same distance.

Accident Diagram

6) Measurements of the damage are critical as well. These can not only validate that the two cars indeed struck one another, but can also provide a biomechanical engineer with critical data when determining velocity and resultant G-forces exerted on the occupants who are claiming injury. When possible, have the measuring device in the photographs.

7) Complete index/background checks on all parties to the accident. This step is critical to ruling out known associates or links to other parties with a questionable claims history. During this stage of the investigation, identify possible parties who can be contacted to corroborate the presented medical history, such as neighbors, co-workers or ex-spouses. In addition, look for professional licensure so as to validate any inability to work that may be presented. Don't forget social networking. With more than half of all social networking profiles lacking the appropriate level of privacy, this can be a treasure trove of information!

8) Have an early settlement or cash-out strategy. While many low-impact claimants seek early attorney representation, not all do. It is imperative to have a strategy to resolve the claims early, and for a reasonable cost. Of course, reasonable is somewhat subjective and is very venue specific. This is why leveraging local counsel and adjusters with local claims knowledge is crucial to achieving a quality outcome. Try to get a handle on what the claimant is seeking to resolve the claim. Sometimes it is as simple as having a doctor visit paid for, other times it may be significantly more.

9) Effective negotiation is the key to resolving these claims. Whether represented or unrepresented, it is imperative that solid negotiations take place. Recognize that the client is telling people he or she is hurt and this will be reflected in the medical records and in a dialogue with the attorney. This is why assessing credibility early on is very important.

Make an early offer and advise that it is final absent objective evidence to the contrary that can be attributed to the claim at hand.

Attorneys should know the limitations of a case if the facts are presented properly. Chances are the attorney never saw the claimant vehicle, so providing 8 x 10 color photographs early in the claim cycle can be very beneficial. Juries rarely are sympathetic to low impact cases, recognizing that these types of opportunistic claims are what drive up their premiums. Attorneys are well aware of this phenomenon.

If the case persists, request an independent medical exam and request a medical history. For these types of claims, asking for a 20-year history is not unreasonable. There can also be significant benefit to utilizing a bio-mechanical engineer to affirm or refute the mechanism of injury. Surveillance can also be very beneficial if there are claims that work or other activities can no longer be performed.

10) While some of these negotiation strategies may succeed in resolving claims early, there will be other times when the claimant or their legal counsel insists on pushing forward. In these instances, the adjuster will ultimately be presented with a demand. It is critical to effectively review the demand with a three-pronged approach for resolution.

  1. Liability – It is crucial that liability be established and argued. Short of a rear-end accident, there is likely comparative negligence involved as many low impact losses occur in parking lots, intersections or during lane changes in heavy traffic. This is an area where carriers often struggle, assessing comparative on only 3% to 5% of all claims presented, while juries consider it in more than half of all cases adjudicated. Leveraging tools, such as ClaimIQ, can provide a dramatic improvement to comparative negligence accuracy.
  2. Special damages – Just because the medical specials are presented doesn't mean that they are reasonable. It is critical to dig into the medical specials to see if bills are reasonable for the zip code where treatment occurred. Moreover, were bills upcoded or unbundled? Was there modifier abuse? Were global surgical edits properly utilized? This is a daunting challenge for adjusters who are already busy, but there are proven solutions, such as Mitchell Decision Point or Smart Advisor, to assist the adjuster with this task. This can provide a tremendous lift, as presented specials can be 30% to 50% more than what is reasonable for consideration.
  3. General damages – Like liability and specials, generals need to be factored in. Is pain and suffering owed for the particular case being evaluated? Is the venue liberal or conservative? In some states, the tort threshold must be pierced.

By developing a solid third-party strategy for low-impact claims, carriers can derive a significant benefit while gaining a competitive edge in the marketplace. It is this type of focus on fundamental execution that enables organizations to go from ordinary to extraordinary.

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