When someone gets hurt in an accident, one of the first steps in seeking compensation is dealing with an insurance company. Whether it’s a car crash, slip and fall, or other personal injury incident, the insurer’s role is to evaluate the claim and decide what it’s worth. This process is often more complicated than it seems. Insurance companies follow a strict set of procedures, and their main goal is to limit payouts.

If you’re filing a personal injury claim in California, knowing how insurance companies evaluate your case can help you avoid common pitfalls and understand what to expect.

Initial Review Starts With the Claim Report

When you file a personal injury claim, the process typically begins with a claim report. This includes basic details about the accident—who was involved, when and where it happened, and the nature of the injury. The insurance adjuster assigned to your case will begin their review here.

From the start, adjusters are looking for red flags. They assess whether the reported facts line up with any available evidence like police reports, photos, or statements. If anything seems inconsistent, they may push back or delay processing.

Medical Records Are a Key Focus

Once the initial report is reviewed, adjusters shift their attention to medical documentation. They want to see when you sought treatment, the type of care received, how long you were treated, and whether your medical providers were appropriate for your injuries.

If you waited too long to get medical help or didn’t follow through on treatment recommendations, the insurer might claim your injuries weren’t serious. If you only visited a chiropractor or urgent care without seeing a specialist, they might question whether the treatment was sufficient or necessary.

In short, medical records form the backbone of your case. Insurance companies use them to determine not just the type of injury, but how it affected your daily life.

Injuries Must Be Clearly Connected to the Accident

Another part of the process is establishing a clear link between the injury and the accident. Insurers look closely at whether the harm you suffered was actually caused by the incident in question or if it may have been related to a pre-existing condition.

For example, if you had a previous back injury and now claim your back was hurt in a car accident, they will likely investigate your medical history. They may even request old records to compare your condition before and after the incident.

If the link between the accident and the injury is unclear, the insurance company may try to reduce or deny your claim altogether.

Lost Wages and Income Are Evaluated Separately

If your injury caused you to miss work, you can request compensation for lost income. The insurance company will typically ask for documentation, such as pay stubs, tax returns, or a letter from your employer. This part of the claim is often straightforward, but complications can arise if you’re self-employed or have irregular earnings.

In some cases, a claim may also include loss of future earning capacity. This is harder to prove and may require expert opinions, especially if the injury affects your long-term ability to work. Insurance companies tend to be skeptical of these claims and may contest the figures provided.

Pain and Suffering Is Harder to Measure

Unlike medical bills and lost wages, there’s no clear formula for calculating pain and suffering. This part of the claim is subjective and often depends on how much the injury disrupted your life.

Adjusters may consider factors like:

How long you were in treatment
Whether your injury left permanent damage
If it interfered with your daily routine or relationships
The emotional impact of the experience

They might also use internal formulas or software systems to assign a value to your pain and suffering. One common method is to multiply your medical expenses by a number between 1.5 and 5, depending on the severity. But these tools often undervalue claims, especially in complex or long-term injury cases.

Adjusters Will Look at Fault and Liability

In California, liability plays a big role in how much compensation is awarded. California follows a pure comparative fault rule. That means you can still recover damages even if you were partially at fault—but your compensation will be reduced by your percentage of responsibility.

Insurance adjusters review every detail to determine who was to blame. They’ll analyze accident reports, witness statements, photographs, and other evidence. If they think you were even slightly at fault, they will likely use it to reduce your payout.

Because of this, it’s critical that any communication you have with the insurer is cautious. What you say, even casually, can be used against you later.

Surveillance and Social Media Are Sometimes Used

In some cases, insurance companies go beyond paperwork. They may monitor your social media profiles or hire private investigators to watch your activity. If you claim you can’t lift heavy objects but then post a photo moving furniture, they may use that to challenge your claim.

Even something as simple as a smiling photo at a family event could be misinterpreted as evidence that you’re not in pain. For this reason, it’s a good idea to stay off social media or keep profiles private during an active injury claim.

They Often Start Low With Settlement Offers

Once the adjuster has reviewed the claim and assigned a value, they may make a settlement offer. It’s common for this first offer to be far lower than what the claim is actually worth. Insurance companies count on injured people being tired, frustrated, or financially stressed.

Many people accept the first offer without realizing they could have received more. That’s why it’s important to speak with a personal injury attorney before agreeing to anything. A lawyer can review the offer, negotiate on your behalf, and ensure you’re not settling for less than you deserve.

Why Legal Representation Makes a Difference

Insurance companies handle claims every day. They know the process inside and out, and they often have lawyers and experts on their side. Most injury victims, on the other hand, are going through it for the first time—while also trying to recover.

Having a personal injury lawyer in California levels the playing field. Your attorney can handle communication with the insurer, collect strong evidence, and push back against low offers or unfair practices.

They also understand how California law applies to your case and can spot issues that might affect your outcome, such as fault disputes or missed filing deadlines.

Take Control of the Process From the Start

If you’ve been injured in California, don’t leave your financial recovery in the hands of an insurance company alone. Know how they evaluate your claim, be careful about what you say, and get medical treatment right away. Most importantly, talk to a lawyer before you accept any settlement.

The better prepared you are, the more likely you are to receive fair compensation for what you’ve been through.

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Michael Waks

Michael Waks is an aggressive advocate for people who have suffered because of someone else’s actions. Michael decided to become a personal injury lawyer when, while clerking at a legal defense firm during law school, he witnessed and was infuriated by asbestos manufacturers spending millions to avoid taking responsibility for the egregious injuries they caused. Immediately after passing the bar, Michael opened his own firm in Long Beach, CA to help the victims of personal injury accidents get every benefit owed them under the law.