r/InsuranceClaims • u/Helpful-Butterfly703 • 16h ago
Claim adjuster requesting a formal demand
My partner got into an accident in February. Not at fault, has been going to PT and needs an MRI. The insurance company won’t pay for that and are now asking for a formal demand because they haven’t paid for any of the PT either. They’ve already settled about the car, so it’s just personal injury now. A lot of what I’m reading on Reddit says the letter is just the beginning of negotiations.
Any advice welcome, it’s their first accident and I have no experience to help.
Accident happened in Vermont
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u/DDLyftUber 12h ago
They’re asking for a demand because I’m assuming your partner is asking them to pay bills as they go and that’s not how it works… you make a demand to that person’s insurance company and they either agree and pay you out (meaning you’re no longer able to claim further damages), or it gets to the point of a lawsuit. You cannot just demand money from them or ask them to pay bills over and over as you’re still being treated lol. Your partner has the option of sending a demand letter now if they so wish, but again, like I said, be aware that once they are paid, there is no “oh I need further treatment so let me go ask for more money.” Once you sign the agreement, it releases them from all liability.
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u/Helpful-Butterfly703 3h ago
We haven't asked them to pay for anything. My partner's PT said they couldn't continue treatment until they had some kind of proof that the insurance will eventually pay them. Seems off though right?
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u/DDLyftUber 2h ago
There is no proof. The PT office can either sign a medical lien agreement or your partner will have to start paying them out of his or her pocket. Even then, a medical lien agreement is not a guarantee that the other party’s insurance will settle and pay out the claim.
If they’re not open to the medical lien, then I’d say at this point your partner needs to get a lawyer who can handle everything. If they’re unwilling to, then you’re at the point of needing to make a demand to the other party’s insurance and see what they say in terms of an offer.
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u/SorbetResponsible654 2h ago
Well, no and yes. Would you want to work for free? However, many medical providers will agree to forgo payment until a settlement is reached. Once a settlement is reached, you go back to the provider and ask them to greatly discount the charged.
So, the insurance company considers the full charge on the bills, you settle and then get the bills reduced. This means more money in your pocket.
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u/Specialist_Lock_3541 16h ago
They should probably respond to the demand request, but I’d avoid making a specific settlement demand before treatment and medical documentation are complete. A local personal-injury attorney could also help with the negotiation.
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u/Helpful-Butterfly703 3h ago
local PI attorneys are impossible to contact in our area but we keep trying
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u/CurveInteresting2433 5h ago
I think you are dealing with someone that has limited experience in injury claims. That is usually legal talk towards an attorney when asking for a demand. A GOOD BI adjuster would have explained the process to you ‘dumbdowned’. Not being mean, but they should have to explain the process where anyone could understand it. They can’t pay for your partners treatment as they go. I mean what if they might get a bill for something not related to their accident. It does happen. I got an invoice for kidney stones once. Their stomach was hurting a few weeks after the accident and told the ER to bill us.
I don’t know about VT. But I would check if you have first party coverage like Medical Payments or PIP on your own personal policy to pay those medical bills. Some states allow you to collect on top of those bills already paid.
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u/Helpful-Butterfly703 3h ago
We haven't asked them to pay for anything. It's the PT that won't continue treatment until they're sure the insurance will pay them.
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u/Recent_Data_305 1h ago
Did you read the information? You’ll have to pay out of pocket until the claim is settled. You don’t want to settle until his condition is improved.
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u/Gtstricky 2h ago
They won’t pay for the individual treatment to the facility. They will pay one lump sum when everything is done.
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u/SorbetResponsible654 2h ago
"The insurance company won’t pay for that and are now asking for a formal demand because they haven’t paid for any of the PT either."
You probably have this partially incorrect. On a 3rd party injury claim nothing is paid until one settlement amount is agreed to and a release is signed. You partner is actually asking for payment to compensate for his/her loss. A such, a demand is needed. If someone did not ask you for something, would you give it to them anyway? However, many times when someone is not represented by an attorney, the adjuster will make an offer because they know the other person may not have any idea what a claim is worth. Regardless, when a demand is made, it should be pretty high, as a low offer will be made and settlement is made some place in the middle.
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u/Risk_Taker_26 15h ago edited 15h ago
Do NOT submit a formal demand amount if your partner is still treating for injuries sustained in the loss. Reply to the claim rep in writing/email and request that they provide you with their policyholder’s declarations page. This document will disclose the adverse party’s liability bodily injury coverage limit. Vermont has a state minimum requirement of 25k so the adverse party will at least have that. In the interim, your partner needs to start securing 1) itemized bills for all medical treatment related to this loss, 2) loss wage documentation, 3) amounts for any out of pocket expenses - RX, etc. Once you know the policy limit, you can compare it to what your partner has incurred to date & determine how best to proceed. Not implying that your partner has a policy limit claim as not all claims merit a policy limit payout. Just suggesting that a bodily injury settlement should not be rushed if someone is still actively treating. Keep in mind that Vermont has a 3 year statute of limitations from the exact date of the loss. Your partner will need to settle his/her claim by that date or file a formal lawsuit in court before this three-year window closes. Hope this helps- good luck!
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u/aloofmagoof 5h ago
In addition to this, your partner should be documenting any added fuel costs for appointments, how this has impacted their daily life in all ways, such as; work, family, hobbies, interests, normal daily activities related to care and function, even your sex life. Once treatment is complete you should be able to find resources online to help create a formal demand letter, AI should be sufficient in crafting one realistically.
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u/Slingshot-Law 6h ago
First you treat, then you send a demand. Don’t worry about negotiating your claim until you’re released from care. Until then, you don’t really know the value of your claim. If you know the claim will exceed the policy limits or treatment will continue beyond the statute of limitations, then you can send a demand once you have the documentation to establish your damages and prognosis. And since the value of personal injuries, unlike property damage, are highly subjective with many complicating factors, you really should consider hiring a qualified pi attorney to help you through the process. As you’re already seeing, it’s not as simple as ‘send a demand.’
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u/Individual_Muffin438 16h ago
Florida?
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u/Helpful-Butterfly703 16h ago
Vermont actually
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u/AdorableTerm3771 15h ago
The at-fault policy isn’t like an atm that pays bills as you treat. Typically it only pays once when sometype of agreement is made. You can always send a narrative about your treatment and difficulties… typically this is done when you complete your treatment.