attorney

Open Letter To Attorney's

Sure Fire Method For Countering Insurance Company Opinions

Are you excited about overcoming obstacles and countering varying opinions that almost always exist on P.I. cases? Probably not. But this strategy might keep you from receiving unfair settlement valuation.

The following information, while lengthy, is serious in nature regarding the multitude of challenges personal injury plaintiff attorneys face along with receiving unfair or low-ball settlements. Some of the information contained within can be disturbing as you discover external limitations which have largely been out of your control, until now. However, the purpose of disseminating this vital data is once known, it can be used to prevent unfair settlements, eliminate varying opinions, establish preponderance and win the presumptive “Great Weight” challenges meeting court approved evidentiary burdens of proof.

 

Without this information, it can result in unintended and disastrous consequences.
Since 2004, injury claim case settlement reserve has dropped from $15,800 to $5,080. Insurers hired consultants who created Business Process Improvement (BPI) which introduced software programs to determine claim settlement valuation. Almost all the insurance companies now use claims settlement software’s to determine settlement value. As the software’s engage cost containment measures to limit bodily injury settlements, it has made it difficult for plaintiff attorneys to oppose without specific knowledge of how the system works.

To understand how this is vastly different from how claim value had been determined previously, it starts by recognizing that there are now 80 different claim settlement software’s in use of which Colossus was the first.

Medical Value Is Either LOST or ACCEPTED into Colossus (and The Other Claims Settlement Software’s)

To use these claims settlement software’s as Colossus, an adjuster inputs data referred to as “Decision Points” and “Value Drivers” about a claim and Colossus calculates a range of values for the claim's worth. The Colossus program can evaluate more than 600 injuries, according to Marion Kelley, representative of Computer Science Corporation (CSC), the company that developed Colossus.

To the degree that the doctor provides adequate medical file chart notes detailing the medical factors listed below, the client cannot get a full settlement evaluation on the case. This is why it is important that the doctors evaluating and treating trauma injuries understand the claims assessment software’s and keep accurate chart notes to assess all the “Value Drivers”. 26 Medical Factors That Should Be Included In Every Medical Chart and Legal Demand:


Such vehicular injuries from the latest edition AMA Guides include;

Mild traumatic brain injuries as concussion, connective tissue contusions, sensory nerve loss, muscle weakness, loss range of motion of joints, upper cervical ligament tears which are diagnosed as ICD-9 728.4 and carry a 25% whole person impairment. (Seen In the 5th edition of the guides, chapter 15, table 15-3a-c, page 379, it tells us ligaments can tear when vertebra have undergone G-forces that cause translation or angular motion of adjacent vertebra induced from the trauma. This injury is referred to in the AMA Guides as “AOMSI” or Alteration Of Motor Segment Integrity. Research reveals these injuries can occur with as little as an 8.2 mph rear end collision.

The latest edition Guides heavily weighs nerve disorders as radiculopathy which can be diagnosed with monofilaments, NCV and provocative neuro-compression orthopedic tests. Heavy value is given even to radiculopathies as motor involvement/weakness of muscles, sensory changes affecting the skin as tingling, etc.

Nerves get injured and pinched and Colossus can trace these injuries into full peripheral involvement.

Oblique Forces Can Cause Vertebral Fracture

Samuel Turek, MD., author of the standard orthopedic textbook used in most medical schools, tells us that in cases of oblique G-forces (such as when the head is turned during impact, looking into the rear view mirror or the car is struck at an angle), this can cause a “minimal derangement fracture” of the upward lateral projections of a cervical vertebra which will not show up for several months. This fracture type is considered a “Derangement Fracture” and rated as a “Specific Disorder Of the Spine” and can bring full case claim value. Most doctors do not assess for a majority of these injuries, especially AOMSI or Minimal Derangement Fracture which can be determined during the process of independent medical validation.

As stated, there are 600 areas of injuries on top of the administrative, legal and economic factors that produce value and which need to be assessed in a Colossus evaluation to input full claim value. Two newer categories that must be assessed include those for loss of function or disability and are now referred to as “Duties Under Duress” and “Loss Of Enjoyment” which carry 50% of the weight of the value of the medical claim. Such factors as “DRE” and “DBI” Categories, “Specific Disorders Of The Spine” and “Spine Impairment Summary” should be assessed to represent and input full value into a Colossus claim and to establish the preponderance.


Colossus Asks Questions About Claim Value

Colossus will bring up “drop-down” screens seeking additional information. Here are some of the “pop-up” questions Colossus will ask when seeking data that inputs value. They represent points of medical validation that comprise value of the claim, which can be assessed during the process of independent medical validation.

  1. Injury types [according to: body parts, functions, systems, organs]
  2. Physical examination findings (type of doctor seen, hospitalization/surgeries)
  3. Clinical evaluation objective tools
  4. Evaluation of injury mechanisms resulting in injury types
  5. Evaluation of loss of function (International Classification Of Functioning – ICF)
  6. Diagnoses (ICD - International Classification of Diagnoses Codes)
  7. Symptoms and Complaints [intensity, frequency, duration, type, radiation, effects]
  8. Duties Under Duress
  9. Loss Of Enjoyment
  10. Documentation of treatment with respect to diagnoses & costs
  11. Prescriptions with respect to treatment, diagnoses & costs
  12. Referrals with respect to injury types
  13. Diagnostics, labs and specialty evaluations with respect to injury types
  14. Immobility devices with respect to injury types
  15. Stability of the medical condition(s)
  16. Static V. Stable injured body parts
  17. Medical determinations overall
  18. Prognosis of each individual body part involved
  19. Prognosis overall
  20. Future treatment plan
  21. Future treatment costs
  22. MMI (maximum medical improvement) per each involved body part
  23. Spine Impairment Summary
  24. Specific Disorders Of The Spine
  25. Regional impairments
  26. Whole Person Impairment rating

If your current medical expert is not supplying you with all these factors in chart notes, the case will lose up to 80% of its value!

While it is accepted and proven that all claims will be devalued due to the use of the insurance company’s software’s, however settling a claim favorably short of trial is dependent upon two main factors:

  1. The physician’s ability to chart the factors of value so they can be input by the software’s and
  2. The attorneys specific mirroring, formatting and sequencing of the factors in the demand letter.

Noted experts in Colossus report that the physician’s chart records (not narrative) are the only source of information that adjusters are allowed to enter into Colossus.

A main objective of the process of independent medical validation is to assess the factors of the case to establish where the presumptive (Great Weight) of the evidence exists.

Not Easy On Medical Evaluators Or Adjusters - But One Side Has Greater Weight


The software’s used by the insurance companies makes a lot of demands on medical evaluators and adjusters, requiring them to enter scores of information. "You have to have a good medical record of what the injury is," says Mr. Smith of American National Property and Casualty Co. "Any injury can have many peripherals attached to it. A neck injury might cause a pinched nerve, which may or may not cause injury down to the fingertip, for example. Colossus is very good at finding out what kinds of injuries are actually present," he says. The more information an adjuster inputs, the more accurate Colossus' calculation becomes.

Today, savvy plaintiff attorneys are referring their cases for the court approved method known as “Independent Medical Validation”, the process to meet evidentiary burdens of proof of impairment in court admissible format, establish preponderance, eliminate varying opinions, win the presumptive “Greater Weight” challenges and prevent unfair valuation.

To effectively represent the client’s injuries and ensure maximum settlement valuation into Colossus and the other claims settlement software’s, physicians and attorneys must learn the requirements of establishing claim value in the medical notes and formulate the demand to be able to include those “Value drivers” to interface with the claims assessment software’s.

Colossus is a computer program that operates on procedural intelligence codes, it doesn’t understand abstract reasoning. You must talk to it in code language.

The more information, Points and “Value Drivers” conveyed, the more the client’s case is worth. The problem is in knowing what the points and value drivers are since they are being kept secret. Since 2004, the insurance companies have been ignoring a Superior Court Order to reveal the “Decision Points”, claiming their right to “Civil Disrespect” and paying ten million dollars in regulatory fines.

Many physicians and attorneys have been kept in the dark, which is another reason to refer the case for independent medical validation, a 2nd opinion accepted by the courts as long as it is independent will provide the Greater Weight according to court definition and authorities.


Attorney Experts on The Subject Say:

Aaron DeShaw, ESQ., in Portland, Ore., has written a book called "Colossus: What Every Trial Lawyer Needs to Know. In his book he says: "While the legal profession has historically used narrative-style demand letters to convey claims, much of the information provided in such a demand letter has no value in Colossus. Adjusters look almost entirely to the medical records for the information required by Colossus. Only a minority of lawyers and doctors have a clue what's going on”.

Las Vegas attorney Steven M. Burris says: When it comes to discussing the damages issues re injuries, the lawyer must stick to the four corners of the medical records documents (Injury Types, % Whole Person Impairment, Duties Under Duress, Loss of Enjoyment). If it is not in the medical records, it doesn't count. Stupid rule, but that's apparently how it's done."


For this reason, as more and more attorneys are becoming aware, the process of Independent Medical Validation is now being used to assess and represent all the applicable injuries to meet the value drivers described above for entry into Colossus and prevent unfair settlements.

When an Independent Medical Validation is ordered by the treating physician himself, it serves as a 2nd opinion which carries great weight of its own in Colossus and provides evidence that the physician is confident his factors can be validated to establish the preponderance. Accordingly, if the physician orders the process, he can submit the expense for reimbursement under the injured’s insurance coverage. Again, the courts define this independent validation as the evidence to win the Greater Weight challenges.

We hope this provides useful data for your consideration to utilize the process as well as provide new hope in eliminating the many challenges plaintiff attorney’s face in personal injury today.