How do insurance decision points affect injury reimbursement?


Decision Points

When an attorney sends a demand package to an insurance company on behalf of an injured client, the insurance adjuster uses decision points to value the claim. Decision points are simply the indicators of the claim that will be considered when calculating the amount of money a claim is worth.

How do insurance adjusters value claims?
The process is supposedly simplified by using computer software to ask questions of the insurance adjuster about the claim. Subjectivity is still involved since the adjuster may not enter the information properly or neglect it entirely. It is difficult to know, but if you are aware of these decision points then you can compile complete and proper notes for the insurance company to evaluate.

How many decision points do insurance company adjusters consider?
An insurance adjuster, through their software, has access to over 10,000 medical, legal, administrative and economic decision points. A legal demand package should include 13 legal decision points and 30 medical decision points for a total of 43 points. The medical notes must be properly documented by the health care professional(s) and the attorney must properly present these requisite decision points to win the Greater Weight of Evidence challenge. (See also: Greater Weight of Evidence post) The medical and legal notes must agree in order for the adjuster to include the decision points into the value calculating software. Even if you are documenting and presenting your information properly you may be sabotaged (albeit unintentionally) by the other legal or medical professionals documentation.

Do you use all of these decision points? If not you should consider them since these points are the basis of value for injury claims.

What are these Decision Points?

  • The 3 Grade Modifiers of the AMA
  • 5th and 6th Edition AMA Guides
  • The Injury Model
  • The DRE Categories
  • The DBI Categories
  • Specific Disorders of the Spine
  • Spine Impairment Summary
  • Whole Person Impairment

It is beyond the scope of this article to review every main Decision Point group, however, we will be expanding on these topics in future posts.


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