Claim | Defined For Texas Personal Injury Cases

In Texas, a personal injury claim is basically a request for compensation when someone gets hurt because of another person’s carelessness. These claims come up in situations like car crashes, slip and falls, injuries at work, medical mistakes, or faulty products.

Handling a claim means looking into what happened, collecting proof, and dealing with the person or business responsible, or their insurance company. If they won’t agree to a reasonable payout, the injured person might need to take the case to court. There’s a two-year deadline for filing these kinds of lawsuits in Texas.

The funds from these cases usually covers costs like medical bills, lost income, and pain and suffering. Understanding the legal framework and procedural nuances of Texas personal injury claims is critical to effectively seeking justice and fair compensation.

What Is a Claim?

A claim is a demand made to an insurance company for compensation. You can either file a first-party claim, or a third-party insurance claim seeking compensation for the damages you incurred after an accident. A third-party claim is one filed with the at-fault’s insurance company after you’ve been injured. 

If you file a third-party claim, you must show that the person their insurance covers was responsible for the accident. This means proving they were careless or acted unsafely and that their actions caused your injuries or damages. These damages might include compensation for bills and financial losses related to the injury, as well as emotional distress.

What’s the Difference Between a Claim and a Lawsuit?

A claim and a lawsuit both involve asking for compensation, but they are handled differently. A claim is made directly with an insurance company, and the process usually involves negotiating with an insurance adjuster. Many claims settle without going to court.

A lawsuit is more formal. It happens when you file a legal case in court because you and the insurance company (or the person who caused the accident) cannot agree on compensation. In a lawsuit, both sides present evidence, and a judge or jury decides who is responsible and how much should be paid.

What Happens After I File a Claim With an Insurance Company?

After you file a claim, the insurance company assigns an adjuster to your case. The adjuster starts by investigating whether the policy covers the accident. They look at details like police reports, your statement about what happened, and statements from their insured.

The adjuster also investigates who was at fault. If they decide their insured is responsible, they may offer you money to settle the claim. It’s important not to accept a settlement too quickly. Accident victims not represented by legal counsel generally receive less than one-third of what they are actually entitled to under Texas law. Insurance companies often offer less than what your claim is truly worth, especially if you do not have a lawyer. 

If the adjuster denies your claim, it does not mean the case is over. Sometimes, claims are denied unfairly or without enough investigation. A personal injury lawyer can review your case and help you decide what to do next.

How Do I Know Whether to Accept a Settlement for a Claim?

Before you accept a settlement, think carefully about your injuries, medical costs, lost wages, and how the accident has affected your life. You should also consider:

Have you finished your medical treatment? 

Ensuring you have received all the care your doctor or medical provider recommends is important, treatments like surgeries, physical therapy, or follow-up visits. If your treatment is not complete, it can be difficult to fully assess the total impact of your injuries and the expenses associated with them.

Are future medical costs covered? 

Some injuries may need care in the future, like more surgeries, therapy, or ongoing medication. Estimating these future costs is important so you are not stuck with unpaid medical bills after your claim is settled.

Have you been fairly compensated for pain and suffering? 

Your claim should include non-economic damages, such as the pain, emotional stress, or loss of enjoyment in life caused by the accident. These damages are not linked to specific bills but are still an important part of fair compensation.

Have you talked to a lawyer? 

A personal injury attorney can review the offer and tell you if it’s fair or if you should negotiate for more. Their advice can also guide you in making informed decisions about whether to accept or negotiate further.

It’s a good idea to avoid accepting the first offer. Insurance companies often start low, hoping to save money. A lawyer can help ensure you get the full amount you deserve.

Reasons Lawyers Typically Reject Initial Claim Offers

Lawyers typically reject initial claim offers and opt to negotiate further due to reasons like:

Low Offers

Insurance companies often make low initial offers. These offers usually don’t cover everything, especially non-economic damages like pain and suffering. Consulting with an attorney can let you know which losses are eligible for coverage, and how to go about obtaining the evidence necessary for negotiations.

Ongoing Medical Treatment

If you are still receiving treatment, your lawyer may advise waiting until your injuries are fully understood. Settling too soon could leave you without enough money to cover future costs, including future copays, medications, therapies, or surgeries. 

Unclear Liability or Policy Limits

If it’s obvious the other party was at fault, a lawyer may push for a higher offer. If your damages exceed the insurance policy’s limits, a lawyer might explore other options, such as negotiating directly with the at-fault party or filing a lawsuit if negotiations are not productive.

Why Do Insurance Companies Deny Claims?

Insurance companies turn down property damage claims for a lot of reasons, which can leave people upset and unsure of what to do. Here are some common reasons why claims get denied:

Policy Exclusions

Insurance policies usually have a list of things they won’t cover. For example, some dog bite policies don’t cover injuries caused by certain breeds they think are "dangerous," like pit bulls or mastiffs. In car accident cases, they might say the insured person caused the damage on purpose, not by accident, which most policies won’t cover.

Lack of Coverage

Not all types of incidents are covered by every insurance policy. For example, in a premises liability case, the property owner may not have purchased a general liability policy. In such cases, injured parties may have to seek compensation directly from the owner rather than through an insurance company.

Non-Payment

If the insured person didn’t pay their premiums on time, their policy could be canceled. If that happens, the insurance company won’t cover anything that occurred while the policy wasn’t active.

Misrepresentation or Fraud

Insurance adjusters may accuse a claimant of providing false or misleading information. For instance, if someone exaggerates their losses or submits inaccurate details about how an incident occurred, the company may deny the claim on grounds of fraud or misrepresentation.

Missed Filing Deadlines

Insurance policies and laws have time limits for filing claims. If you fail to meet these deadlines, whether outlined in the insurance policy or under the statute of limitations, the insurance company may deny it, even if it is valid. Insurance policies and state laws often require claims to be filed within a specific timeframe.

Pre-Existing Damage

Insurance companies might say the damage was already there before the incident happened. For example, after a car accident, they could claim that scratches or dents on your car didn’t happen because of the crash but were already there before.

Failure to Mitigate Loss

After something goes wrong, insurance companies expect you to take reasonable steps to keep the damage from getting worse. If you don’t, they might not pay for extra damage. For instance, if a storm breaks a window and you don’t cover it, they could refuse to cover water damage caused by rain coming through the open window.

Insufficient Evidence

A lack of documentation is one of the most common reasons for claim denials. You may need to provide extensive evidence such as receipts, repair estimates, photos, videos, and witness statements to substantiate your claim. Without this, the insurance company may argue that your claim is unsupported.

Negligence

Sometimes insurance companies say the damage is partly your fault because you didn’t take care of the problem. For example, if a pipe bursts in the winter because you didn’t insulate it, they might argue that it’s your fault and refuse to pay for the repairs.

Policy Limits

Every insurance policy has a maximum amount it will pay for a claim. If the damages exceed the insured’s policy limits, the insurance company may deny part or all of your claim, leaving you to seek the remaining compensation from the at-fault party directly.

Human Error

Sometimes, claims are denied due to simple administrative mistakes. For example, a claims adjuster might enter incorrect information about the policyholder or the claim, leading to an unnecessary denial.

Factors That May Influence Your Decision to File a Claim or Lawsuit

Several factors can impact whether you decide to file an insurance claim, appeal a denial, or pursue a lawsuit:

The Denial Letter

The denial letter from the insurance company outlines their reasons for rejecting your claim. Carefully reviewing this letter can help you understand whether their decision was based on a valid policy exclusion, lack of evidence, or another issue.

The Amount of Compensation You Seek

If the damages or losses you’re seeking are relatively small, you might decide that pursuing the claim isn’t worth the time and effort. However, for significant amounts, it may be worthwhile to fight a denial or escalate the matter to a lawsuit.

The Facts of the Case

The strength of your case will play a major role in your decision. If you have strong evidence that supports your claim such as photos, repair estimates, or witness statements, it may be easier to contest the denial or succeed in court.

How Much Effort You Want to Commit to the Process

Filing an insurance claim or lawsuit can be time-consuming and stressful. It’s important to weigh the potential benefits of pursuing compensation against the time, energy, and possibly legal expenses involved. A strong legal team can help streamline the process, but the decision ultimately depends on your willingness to engage in what could be a prolonged dispute.

What Can I Do If My Insurance Company Denies My Claim?

The only option after receiving a denial from an insurance company is to have a personal injury attorney review the case and determine if filing a lawsuit against the at-fault is a viable option. 

A denial does not mean that you do not have a valid claim.

If the insurance company denies your claim, don’t give up. A personal injury lawyer can review your case to see if a lawsuit against the at-fault party is a good option. Many claims are denied unfairly, and a lawyer can help fight for the compensation you deserve.

What Is a Personal Injury Lawsuit?

A personal injury lawsuit is a civil lawsuit is filed in State of Federal Court. You, the injured person, are the plaintiff, and the person who caused the accident is the defendant.

During the lawsuit, both sides collect and share evidence in a process called discovery. If the case doesn’t settle, it goes to trial. At the trial, a judge or jury decides who was at fault and how much compensation to award.

To win a personal injury lawsuit, you must prove key elements of negligence, including that the defendant had a duty to act safely, that the defendant failed at their duty by acting carelessly or unsafely, and that their actions caused your injury. Once liability is established, your lawyer must show that you suffered damages like medical bills, lost income, or pain and suffering, and calculate the costs that the defendant should pay.

Texas has specific rules about fault. If you were partly responsible for the accident, your compensation might be reduced. However, if you were mostly at fault (51% or more), you cannot recover any money.

How Can a Lawyer Help Me With a Claim?

A personal injury lawyer can be your strongest advocate after an accident. They understand how insurance companies work and can negotiate to get you the compensation you deserve. Insurance companies often undervalue claims, especially if you don’t have legal help.

Your lawyer will calculate all your damages, including future medical costs and pain and suffering, to ensure you aren’t shortchanged. They also know Texas laws, which can be complicated, and handle the legal process so you don’t have to.

If your claim doesn’t settle, your lawyer can file a lawsuit and represent you in court. Having a legal expert on your side gives you a much better chance of getting the full compensation you need. If you need an attorney’s guidance to help you through the complexities of an injury claim or lawsuit, contact Sneed and Mitchell at (866) 434-0014. Our team is available 24/7 in multiple offices throughout the state to discuss your legal options right away.