Some personal injury claim settle sooner and with less controversy. Others take months or years, require extensive negotiations, expert testimony, and eventual litigation in some cases. The difference isn’t mere happenstance, though—various factors dictate whether claims are simple or complex. While not every claimant with an injury can anticipate exactly what will happen with their claim, knowing these factors helps set expectations of what might be involved.
Furthermore, complexity isn’t always based on injury severity, which surprises people at times. A complicated claim can come from an incident with minor injuries or even no injury where liability is certain; a straightforward claim can have substantial complications when the issues are worse than the injury. It all depends on whether various factors come together as expected or if they require additional time, resources, and effort to determine eligibility.
Factors that make simple injury claims complex include:
Disputed Liability vs. Clear Responsibility
The most significant factor that dictates whether a claim is simple or complex stems from whether fault is established. With clear liability—a rear-end collision with extensive damage, video evidence of a slip and fall, or a malfunctioning product with a history of grievances—settlements come quickly. The insurance company knows that its client will lose in court and so is more amenable to settling out of court.
Where fault is disputed, everything becomes more complicated. Multiple parties attributing the fault to the other; conflicting eyewitness statements; no tangible evidence to clear up the matter. All of this requires investigation, expert review, and inevitably litigation to determine the facts. This is where a personal injury lawyer can be helpful to assess whether fault requires a complicated examination of fault.
Further, shared fault is even more complicated. In cases where comparative negligence applies, percentage attribution requires extensive review. A case where the claimant is 30% to blame resolves much differently than one where the claimant has 0% fault.
The Relevance of Documentation
When a claim has been well-documented, it operates smoothly. Medical records delineate a specific injury attributable to the accident. Police reports indicate what transpired. Pictures of the scene and vehicle damage are taken. Witness information is collected in short order. When all of this documentation exists and paints a collaborative story, there’s less to go to mediation over.
When documentation fails to exist or occurs poorly despite otherwise clear cases, it’s complicated. Delays in medical treatment—where insurance companies try to claim that injuries are not major; nonexistent police reports; a lack of pictures showing what caused a slip and fall; witnesses who disappear without statements—all of these gaps become something that goes against claimants instead to making processing everything complicated.
Medical documentation is even more crucial to successful claims. A clear diagnosis after an accident, recommended treatment that continues at appropriate intervals, and includes cumulative care all support claims well. Gaps in treatment when an insurance company attempts to claim that injuries weren’t that bad are complicated. Changing recommendations in diagnoses or health records indicating pre-existing conditions complicate matters immensely. The insurance company will look into medical records extensively to find any reason to deny validity for high compensation.
The Type and Severity of Injuries
Injuries that are objective and have related medical findings strike simplicity. A broken bone can be seen on X-ray; a surgical report can detail mending efforts; these injuries are hard to refute. Soft tissue injuries, complaints where there are no objective findings during the emergency stages, or conditions that take weeks to develop, complicate matters in proving them worthy for compensation.
Regardless of how clear they may be objectively, permanently disfiguring injuries are complicated relative to what’s presented. Future medical challenges must be projected; lost wages must be calculated; life care plans are necessary for implementation; these developments require expert testimony with insurance companies ready to vigorously challenge all positions.
Pre-existing conditions are complex injury claims’ worst nightmare. Insurance companies maintain that based on existing documentation of previous issues that were not part of this incident—insurance companies do not have to pay for current problems. Even if an injured party has a pre-existing condition or injury exacerbated by the new situation, it’s up to medical experts with potential for competing viewpoints to establish causation.
Insurance Coverage Complications
When coverage is clear and comprehensive for all involved, claims are processed faster. The responsible party has a solid policy with limits that cover damages assessed. The terms of the policy are easy and the insurance company has the authority to settle within policy limits.
However, coverage disputes complicate matters tremendously. An insurance company might claim that policies do not cover this type of incident, but there’s another policy that does cover it. One policy isn’t responsible for itself, while another policy is sharing coverage, which muddies attribution. Policy limits could be substantially less than what’s required for final medical treatment—and then uninsured or underinsured motorist claims make matters worse. Every coverage gap becomes an issue that must be resolved separately—and takes time.
Multiple responsible parties create more chaos than singular ones. One person/entity responsible for an incident either pays for themselves or their insurance company does; however, multiple parties involved cause accidents—many vehicles crash into one another; one property owner supervises while another maintains—it gets complicated. Manufacturing products requires wholesaler policies as well as retailer attribution; employers are involved with employees.
Where multiple parties get involved, they point fingers elsewhere in an attempt not to take accountability for themselves. Cross-claims come up where those accused sue each other; claimants get caught in the middle as their case is delayed while responsibility among faulted parties is determined.
Third-party claims involve workers’ compensation when another employer injures someone; third-party medical malpractice inadvertently involves multiple providers; third-party construction accidents involve many contractors/subcontractors—each additional party adds more convoluted insurance companies, lawyers, and discussions.
Complicated Calculations
Simple calculations for damages settle faster; established medical bills, documented lost wages, and easily calculated out-of-pocket expenses—they resolve as long as everything is documented objectively without question. Simple economic damages have less problematic negotiations—what amount seems fair?
Complicated non-economic damages prevent settlements from resolving quickly—pain and suffering, emotional distress, and loss of enjoyment of life—these aren’t quantified in receipts or bills; the claimant generally recommends an appropriate number that an insurance company rarely finds agreeable. Without objective measures, no amount is too low or high enough aside from time spent negotiating based on subjective presentation.
Future damages require prediction, which incites experts who have various opinions on both sides about how much future medical care will cost, what present value lost wage potential equals, and what sounds reasonable for permanent disfigurement—economically speaking, these evaluations can also be skewed based on those discussions.
Willingness to Negotiate
The type of approach an insurance company takes goes a long way in establishing complexity. Some offer reasonable amounts after assessing claims objectively; others start low or very high when it sounds like nothing is going their way; some essentially force claimants to litigate just to receive proper compensation.
The same case can go through differently depending upon which insurance company assesses the situation without discerning variables aside from adjuster intent—even within one company at times—as some go for amicable resolution while others attempt to deny/minimize every claim possible through determination.
Why This Matters
Reasonable expectations should be established once aware of the factors of complexity vs. simplicity status. If liability is upheld, documentation is in order, and injuries warrant validity based on severity and need, with proper coverage, compensation arrangements should come through quickly through fair appeals.
However, if disputed fault exists with inconsistent documentation based on poor decisions through easy solutions—and then disputed comparative data with other responsible defendants—it’s going to take years.
This isn’t fair, and it’s not how it should be—it should apply practically based on circumstances outlined above—but knowing which points apply helps identify what’s ahead and whether an attorney is justified in being present (an area where simple claims don’t necessarily need them but complex claims do).
Moreover, not every factor creating simplicity/complexity from factors is evident at first blush; what seems like a straightforward process becomes complicated due to levels of documentation occurring later down the line—coverage unavailable at first purchase by another party but known later after due diligence—or an insurance company balking at any settlement unless litigation occurs due to unreasonableness of how they look at everything—avoidance of expectations creates surprise frustration when simple claims fall outside parameters because they were unclear from the onset on what would transpire naturally.
