Why insurance claims for soft tissue injury are so critical?

by Modelkrb » Mon Apr 13, 2009 10:01 pm

Filing for an insurance claim is a tedious process. You eventually get paid for the losses, but only after the insurance company verifies that your claim is authentic. You would rather not expect them to pay more than what your loss had been. On the contrary, the insurers may try in every way to pay as less as possible. In that case, you may have to fight hard to receive a satisfactory compensation. Demanding insurance compensation for soft tissue injuries might be all the more difficult.

What is a soft tissue injury?

Soft tissues in a human body include everything except the bones and the organs. Thus, any injury to the muscles, ligaments, tendons, and other connective tissues can be termed as a 'soft tissue injury'. Bruises, sprains, strains, abrasions are the common soft tissue injuries that might affect an individual. Whiplash is one of the most prominent forms of soft tissue injury that affects the neck and upper back of the individual, if his/her car is rear-ended during an accident. Top

When to claim compensation for a soft tissue injury?

Claims for the soft tissue injuries are incorporated as a part of personal injury compensations that you can seek from your insurer after an accident. It is only justifiable to file a soft tissue injury claim when the injuries have been caused by:
  1. Auto accident
  2. Reckless or violent activity
  3. Defective equipment
  4. Defects in playing surfaces
  5. Lack of proper supervision
  6. School sporting activitiesTop

How are the injuries treated?

The soft tissue injuries cannot be easily diagnosed and there are no specific treatments for such injuries. However, health care specialists often use prescription drugs to relieve the pain from the injuries. The most recommended forms of treatments include:
  1. Rest
  2. Physical therapy
  3. Chiropractics
  4. Oral pain relievers and muscle relaxants
  5. Soft cervical collars (to immobilize neck after a whiplash injury)
  6. Massage
  7. Heat
  8. Ice
  9. Injection
  10. Ultrasound.
    11. Top

Why soft tissue injury claims are different from other injury claims?

Soft tissue injuries cause pain and soreness to the affected individual. Not only that, it also affects the earning capability of the individual. However, unlike other injuries, it's difficult to document them. Most of the time, the injuries don't show up on the skin. Even X-rays may fail to point out that injury in the area. The treatments may not follow the conventional path, as for other form of injuries. It's also hard to determine the claim amount for pain and suffering and loss of pay. The insurers often take a long time to settle a claim for a soft tissue injury. Often, the injured has to go to a trial to get a reasonable amount as compensation. Top

How much to claim for settlement of soft tissue injury?

The claim amount for soft tissue injuries differs from person to person. Your soft tissue injury settlement claim would depend mainly upon the factors mentioned below:
  1. The treatment - Your diagnosis and the mode of treatment will affect the claim amount, since you'll be asking your insurer to reimburse the corresponding expenses.
  2. Your income - Your income will affect your claim amount, since you'll be asking compensation for the loss of pay. Losses of past and future income along with the cost for future care are included when an insurance claim is filed. Besides, it would also depend upon the duration for which you were unable to work.
  3. Attorney fees (if any) - In case you're hiring an attorney, your claim amount should be more than the actual expenses for the treatment and loss of pay. It is so, since the attorneys deduct a share of the settlement amount that the insurer pays you.Top

Points to remember when filing claims for soft tissue injuries

Certain factors should be kept in mind, if you want to file an insurance claim for a soft tissue injury, as mentioned below:
  1. Take pictures of any visible symptoms - It is difficult to prove the extent of injuries. Therefore, any physical symptoms like swelling or bruising should be documented with the help of photographs.
  2. Save the documents - All details of medical advices and treatments should be stored in a proper order. You might need them to substantiate the treatments for your injury.
  3. Negotiate on your own - Try to settle the amount yourself initially. Negotiate with your insurer to arrive at a reasonable claim amount.
  4. Consult an attorney - Hire an attorney to represent you, only when your insurer refuses to pay anything. You should keep in mind that you'll need to pay the attorney, out of the claim amount that you receive.
  5. Don't make haste - You must have patience when dealing with your insurer. A settlement will take time, if you want to receive a decent amount at least. You can claim for any soft tissue injury, if the other party is responsible for it in any way. Every insurance claim needs to be proved. As for a soft tissue injury claim, substantiation is all the more vital.

You can claim for any soft tissue injury, if the other party is responsible for it in any way. Every insurance claim needs to be proved. As for a soft tissue injury claim, substantiation is all the more vital.Top

Related discussions

i have a similar post but i am going to go into detail with this.i need you alls advice.i am wondering what is the highest amount i can get from soft tissue injury settlement after my attorney takes her 33 percent out.Here Is My Situation,On December 26,2008 I Was At A Stop Light Waiting For It To Turn Green.The Light Finally Turned Green.As I Was Pulling Off The Lady Behind Me Ran Right Into The Back Of Me.We Pulled Over She Came To Check On Me To See If I Was Ok.At The Time I Was Fine.She Immediately Got On Her Phone And Called Her Insurance Company In The Process Of Doing That She Was Telling Me I Dont Have To Call The Police She Will Take Care Of My Car.I Called The Police Anyway To Make A Long Story Short She Ended Up Getting A Citation For Following To Close.This Was 11am On A Friday.I Didnt Feel Sore Until I Want To Say 12 To 1.A Member Of My Church Reffered Me To An Attorney,She Gave Me The Name Of A Chiropracter To Go To.I Went In And Basically I Went For 3 Months At 3times A Week.To Make A Long Story Short My Car Damage Was 559.78 .My Lawyer Said That Usaa Doesnt Believe That The Damage To My Car Was Bad Enough For Me To Be Hurt.If I Wasnt Hurt I Would Have Never Went Threw The Process Of All Of This.My Lawyer Asked Me To Contact My Insurance Company To See How Much Is My Med Pay.Ok To Make Another Long Story Short My Entire Bill With The Dr Was 3,692 And Some Change,My Med Pay Paid My Entire Bill So I Am Ok With That Portion,My Lawyer Put A Demand To Usaa For 16,000.I Understand I Am Not Going To Get That Much Back.Usaa Is Offering 4,225 That Is Too Low And My Lawyer Already Said She Is Going To Put In Another Demand.My Question To You All Is What Is The Most I Can Get From A Soft Tissue Injury Settlement Claim.If You All Have More Advice For Me Feel Free To Reach Me On Yahoo Messenger My Id There Is Kai30034 I Need All The Advice I Can Get.

Total Comments: 97

Posted: Wed Oct 03, 2012 07:07 am Post Subject: settlement amount?

I'm 22 and from Milwaukee WI. July 9th a driver pulled out into 2 lane traffic and I hit him after screeching on the breaks. I was found 15 percent at fault because cars in the turn lane that prevented me from seeing the driver, the same cars that prevented him from seeing me. I had bruises and scratches from stomach to chest from seat belt and burns on my arms from air bags. I also had a minor concussion. I was offered 1000. 3 days after the accident I realized the foot pain wasn't going away and I started getting headaches everyday. I declined the offer and went to the dr. After xrays they found that my neck was straighter than it should be due to whiplash. I was sent to physical therapy for the foot muscle strain and whiplash. After 2 and 1/2 months of physical therapy, headaches and migraines daily which prevented me from sitting more than 15 mins and driving longer that 15mins. I was miserable everday with pain at a 6 for hours a day. I tried 3 different types of muscle relaxers. I even had one ER visit (due to the worse headache I've ever had in my entire life) I also had 2 apts with neurologist because my primary dr referred me. I'm doing better now. $7000 medical bills. $200 wage loss. $100 shoes my physical therapist documented that I needed. $.75 for prescriptions and other medical stuff like icy hot pads, tennis balls (recmnd by physical therapist) and $105 in milage for apts at the states .47 a mile. Where do I even start for an amount on my demand letter. Additionally, what's a reasonable amount to settle for?

Posted: Wed Oct 03, 2012 10:49 am Post Subject:

Where do I even start for an amount on my demand letter. Additionally, what's a reasonable amount to settle for?


You start by listing all the expenses you have listed here. Expect the insurance company to deny many of them (if not most). Things like corrective / orthopedic shoes are almost always going to be denied, on the premise that their need was something unrelated to the accident.

You will have to fight them on that, based on medical records and expert witness testimony from your physician (or another physician, which may not be as credible). Insurance companies frequently look at claims like yours as an attempt to collect money for things that aren't collision related, which might, legitimately, be examples of insurance fraud.

If you can affirmatively show that your expenses were 100% related to the collision, and you agree that your share of fault was 15%, you are entitled to 85% of the expenses incurred. Those are known as "specific" or "special" damages. They are documented with bills from health care providers.

When it comes to "general" damages for pain & suffering, those claims are subjective, and insurance companies don't like paying them, because they are not verified by any documentation (other than psychiatrist's or physician's notes, as an example). No one can tell you what they are worth, if they are worth anything at all.

What do you settle for? That, too, is a tough call. Before you get an attorney involved, you add up your actual expenses, deduct your 15% (perhaps), and some folks say multiply that number by 2 or 3 or more as a way to state "pain & suffering" as a dollar value. So let's just say, with medical expenses and lost wages of $10,000 - $1,500 = $8,500, you might ask for $17,000-$25,000 as your general damages.

The insurance company will counter offer something less than that, like $5,000.

You have to decide whether to accept that or not and keep up your demand for a larger settlement. When you come to the point that what you are asking for and what the insurance company is willing to pay is not moving in your direction, then you begin to think about involving an attorney. But the attorney is going to demand between 30% and 40% of whatever settlement or jury award you are given.

And that's where you have to do the math. Let's say the insurance company offers to reimburse for all your specific damages (anything paid for by other insurance will have to be turned over to the other insurance companies, such as your medical insurance (or your employer's workers comp, if you received a WC benefit, for example). And let's say the insurance company offers you $10,000, but no more than that, for your general damages.

If your attorney does no better for you than that which you could have had on your own, you are the big loser. Because your attorney's 30% is based on the total settlement. $8,500 + $10,000 = $18,500 minus $5,550 (or more) = $12,550 minus $8,500 = $4,050 (or less) in your pocket. You could have had $10,000. That $4,050 is actually 60% of what you could have had on your own. You get $4050, your attorney gets $5550. Who won?

Not you.

So just be aware of all those things. And if your collision-related medical expenses
will last many years into the future, you need to consider that as well, and make it part of your claim for damages.

Posted: Fri Oct 05, 2012 07:28 am Post Subject:

Thanks for the quick response. My apologies for not posting a new thread; to be honest forums are a tad confusing to me.

I have a few more questions. I consulted a lawyer and he said he would add up the total amounts billed to my health insurance, not how much I'm actually paying out after my health insurance. I called my health insurance, the amounts totaled billed to them is at 11,000 and what I actually owe is 2000. Your thoughts on this matter? I ask this because in your example calculations showed my health insurance would basically intercept that money. Which is understandable! I don't want anyone to go unpaid. I just want this all to be said and done. Does the example of calculations differ now because the amount billed and amount owed are 2 different amounts?

In the calculations example you said 8500 +10000. The 8500 being 85% of total medical and lost wages. Is the 10000 what you considered to be solely pain and suffering (to compensate me for pain...)? To clarify my question further, In your example, they would pay 8500 for medical and then 10,000 because I've dealt with crazy headaches & migraines every single day (the actual pain and suffering portion)?

Also, the shoes were required because of a pulled muscle that went from my foot to knee.(This was a result of hitting the brake too hard) Which I was sent to physical therapy for combined with the whiplash. The physical therapist did document that I needed the shoes for the proper healing environment.

I hope that I'm clear and concise with my questions. This is all a little overwhelming. Thanks in advance for your answers

Posted: Fri Oct 05, 2012 10:47 am Post Subject:

I consulted a lawyer and he said he would add up the total amounts billed to my health insurance, not how much I'm actually paying out after my health insurance. I called my health insurance, the amounts totaled billed to them is at 11,000 and what I actually owe is 2000. Your thoughts on this matter?


Yes, that's the appropriate thing to do, but it is a double-edged sword . . . cutting away at your net settlement. Because the more the attorney "gets" for you in the settlement, the more he pockets, too. And, regardless of what the attorney "gets" for you as a settlement, your health insurance is still entitled to 100% of its expenses paid on your behalf, the reason being that your health insurance is not supposed to be used for third party claims (it is only intended to be used for your own medical expenses -- things that happen to you through no one else's fault).

But your attorney gets to take his 30%-40% OFF THE TOP before anyone else claims a share. So -- without a trial -- let's say your medical expenses are $11,000 and lost wages are $4000. If he gets you a settlement of $15,000 for medical expenses and lost wages, plus $7500 for pain and suffering . . . a total of $22,500 . . . and he has a 33.33% fee agreement, his cut is $7500 off the top. Your health insurance company is still entitled to recover up to $11,000.

If you cannot negotiate a reduction in their subrogation claim, you have to pay them $11,000, less your offset for any copays or deductibles (let's say $2,000). So $22,500 - $7,500 - $9,000 = $6,000 to you . . . essentially all you take from this is your lost wages plus reimbursement for your out of pocket expenses (actually a bit less, since the attorney will take some pretrial expenses, like court filing fees, off the top, too). So much for all the pain and suffering. Your attorney gets almost double what you net ($4,000). And your health insurance gets all of what it paid minus what you paid . . . and they expended no time, effort, or money to collect their share.

For those folks whose attorneys "overlook" the health insurance company's subrogation right, they do even worse. And if you go to trial, are found 15% at fault, your award is reduced by that amount. And the health insurance company still gets its full share unless you can negotiate a reduction (you could fairly argue the 15% contributory negligence offset) .

In your example, they would pay 8500 for medical and then 10,000 because I've dealt with crazy headaches & migraines every single day (the actual pain and suffering portion)?


Yes, this was based on a trial outcome where your contribution was assessed at 15% (applies to both expenses and pain and suffering) -- but the numbers were not intended to predict the outcome of your case, they were simply round numbers for illustration purposes.

The main point of the illustrations is to show you that the attorney's take will almost always be more than yours. Especially on smaller outcomes, which is what I envision yours would be.

So, on your own, you try to negotiate the best outcome you can, knowing what your health insurance company is entitled to be paid. What's left is yours. An attorney would have to do his share better for you than that to even make hiring an attorney worth the trouble.

If you don't feel the insurance company is being fair to you, then you hire the attorney, but that's no guarantee of a better outcome. Any attorney who promises you more is not to be trusted. When you look closely at the fee agreement, all he is promising is to get you a settlement offer, not a positive outcome at trial. If you turn down the settlement offer, not only will you pay him his 30%-40%, but he'll also charge you for all the expenses of trial, too -- if you win. And if he forgets to add those charges into the original complaint, you can't collect them from the other party if you win the matter at trial.

If you lose, you'll pay your attorney some exorbitant hourly fee (like $300-$500) plus the expenses of trial. His fee agreement doesn't exactly say what you thought his television commercials did, "If you don't win, you don't owe us anything." Listen more carefully, and you're likely to hear, "If we don't get you a settlement, you don't owe us a thing." The fee agreement will talk about a pretrial or prejudgment settlement "offer".

So, figure out in your mind how much you want in your pocket after all your direct medical expenses and lost wages were. Add those amounts to your "pocket" and that's what you ask the insurance company for. Assume they will offer you half of that, so you might want to increase what you are asking for (after medical expenses and lost wages) by 100%. If you want $10,000 plus, you ask for $20,000 plus.

You should also prenegotiate a subrogation amount with your health insurance company. If they are entitled to $11,000 - $12,000, ask them to reduce their take by 50% and see what they offer in return. To them, anything is better than nothing if they don't have to hire an attorney, since it could cost them 30%-40% to collect their 100%. So, getting a reduction to 60%-70% of $11,000 would be pretty good on your own. You still get your $2,000 offset against that (but that's negotiable, too, and they might want you to give up some of that -- but you don't have to, since you actually paid it).

And, don't forget, their $11,000 could be a "phantom" number. They may have received "billings" from physicians and others totaling $11,000, but only paid those folks $5,000. That's what you really need to know -- how much they actually paid. It could be less than half of what was "billed" because they have negotiated rates with their network hospitals and physicians and other providers.

It's a wonderful game that gets played from several angles. Fail to play by the rules, and you are the one who gets hurt (maybe even worse) the second time.

Hope this helps.

Posted: Mon Oct 29, 2012 05:00 pm Post Subject: claim

I am wondering what a fair settlement amount is for my case. The other party is assuming 100% fault, the damages to my vehicle were around 4,000$which I received. The doctor bills for me and my two children total around 11,000$ I have been on prescription pain meds since may 7th when the accident occurred. I was last week released by the chiropractor and today released from physical therapy from the personal injury claim. I was treated for whip lash and a sprain to my lower back-hip area My children were both treated for whip lash as well but where released from the claim a few months ago. The other parties insurance company is State Farm. I am just wondering what is a fair amount to expect from this claim

Posted: Mon Feb 04, 2013 03:59 pm Post Subject: car accident

have a back spain and neck sprain and really bad panic attacks now medical bills are about 3000 now how much should i ask for.

Posted: Mon Feb 04, 2013 06:34 pm Post Subject:

No one here can tell you the answer to that question. You are entitled to 100% of your medical expenses. What are "panic attacks" and why do they have anything to do with a collision?

Posted: Mon Mar 11, 2013 08:07 pm Post Subject: Rear ended 2 weeks ago

Long story short ; got rear ended 2 weeks ago while I was at a stoplight waiting for light to change , my car was totaled by at fault driver's insurance . X-rays were taken and according to my chiropractor I have a soft tissue injury . I've been seeing my chiro everyday , missed 10 days of work at her recommendation . Headaches still after 12 days but decreasing in intensity . Adjuster met with me after the incident and gave me the claim number to bill everything under their name. I know it might be a little premature to talk about a settlement but what $$ should I be aiming for ? I don't want to get a lawyer involved but I don't want to get a lowball offer from insurance ? Would like a fair amount for all my troubles . Any suggestions ? Thanks in advance !!

Posted: Tue Mar 12, 2013 12:12 am Post Subject:

Any suggestions ?

Posted: Fri Mar 29, 2013 06:32 pm Post Subject: curious

My wife and I were involved in a rear end collision. It totalled our vehicle ($21000) and we had $54000 worth of medical bills. We were in physical therapy for approx. 3 months. We had no breaks or scars, just neck sprain(both), back strain(both) and limited range of motion (wife's arm). My wife kinda freaks out when traffic gets somewhat conjested now also, whether she's driving or not. Does anybody know a ball park figure that should be reasonable for pain and suffering?

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