How Insurance Adjusters Minimize Your Georgia Injury Claim

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An adjuster represents the insurer’s interest in a claim, and much of what moves a claim’s value happens through ordinary steps: a recorded statement, a records request, an examination, a first offer, a fault percentage. Georgia regulates that conduct, but only at its edges. The Insurance Code lists sixteen unfair claims settlement practices, and none becomes a violation unless the insurer commits it flagrantly and in conscious disregard of the law or with enough frequency to show a general business practice. Below that line, the steps are negotiation.

The Georgia Rules That Limit an Adjuster

OCGA 33-6-34 lists the practices. Those relevant to a claimant include knowingly misrepresenting to claimants and insureds relevant facts or policy provisions relating to coverages at issue; failing to acknowledge pertinent communications with reasonable promptness; not attempting in good faith to effectuate a prompt, fair, and equitable settlement of claims in which liability has become reasonably clear; and refusing to pay claims without conducting a reasonable investigation. When the insured asks in writing, an insurer must also promptly give a reasonable and accurate explanation of the basis for a denial or a compromise offer, and denials must be in writing.

OCGA 33-6-33 sets the threshold. An act on the list is an improper claims settlement practice only if it is committed “flagrantly and in conscious disregard” of the insurance title or its rules, or with such frequency as to indicate a general business practice. Enforcement runs through the Commissioner of Insurance, by statement of charges, hearing, and the cease-and-desist and penalty procedures that OCGA 33-6-35 borrows from the general insurance hearing provisions. The list marks the outer boundary of conduct, and it reaches an offer only in defined circumstances, such as compelling insureds or beneficiaries to sue by offering substantially less than the amounts they later recover (OCGA 33-6-34(5)).

The Recorded Statement

An adjuster for the at-fault driver’s insurer may ask a claimant for a recorded statement early in the claim. Questions can cover how the crash happened, where it hurts, and whether the same part of the body was injured before. A statement fixes the claimant’s account at a moment when the full extent of an injury may not yet be known, and an early “I feel fine” can sit awkwardly beside a later diagnosis. Questions about earlier injuries can lay the groundwork for an argument that a current complaint predates the crash.

A cooperation clause is a term of an insurance policy, so it binds the parties to that policy. The at-fault driver’s insurer is not a party to a claimant’s own policy.

Medical Authorizations and the “Independent” Examination

A medical-authorization form can cover more than treatment connected to the crash. The wider the authorization, the more of a claimant’s medical history is available for causation arguments.

An examination by a physician the insurer selects may be described as independent, but that label does not appear in the statute. In a pending lawsuit, OCGA 9-11-35(a) allows a court to order a party whose physical condition is in controversy to submit to a physical examination by a physician, but only on motion for good cause shown and with notice to everyone involved. The order must specify the time, place, manner, conditions, and scope of the examination and who will conduct it. That statute works through the court in which the action is pending, so it compels an examination only once a lawsuit is pending.

Time-Limited Offers

For motor-vehicle collision claims, OCGA 9-11-67.1 governs time-limited settlement offers prepared by or with the help of an attorney before the defendant’s answer is filed. Such an offer must give the recipient at least 30 days from receipt to accept, and it must be sent by certified mail or statutory overnight delivery (subsections (b)(1)(A) and (g)).

The statute also gives an insurer a path away from a later failure-to-settle action. There is no civil action for an alleged failure to settle if, by the dates in the offer, the recipient provides a writing that accepts the offer’s material terms other than the amount, a sworn statement about insurance coverage if the offer requires one, and payment of the lesser of the amount demanded and the available bodily injury limits (subsection (i)(1)).

Fault and Causation Positions

Every percentage point of fault assigned to a claimant reduces the recovery, and at 50 percent the claim ends (OCGA 51-12-33). An adjuster’s position on fault therefore carries direct weight. A claim at 20 percent claimant fault is worth 80 percent of the damages a jury finds; at 50 percent it is worth nothing. A causation position works differently. Attributing a complaint to a prior condition or a gap in treatment attacks the link between the crash and the injury rather than the amount. Both positions are resolved by evidence, not by the offer.

When Insurer Conduct Crosses Into Bad Faith

A separate remedy exists in first-party cases. When a covered loss goes unpaid for 60 days after the policyholder’s demand and the refusal is found to be in bad faith, OCGA 33-4-6 makes the insurer liable, in addition to the loss, for a penalty of not more than 50 percent of its liability for the loss or $5,000, whichever is greater, and for reasonable attorney’s fees. The remedy belongs to the holder of the policy, not to a third party claiming under someone else’s policy.

Frequently Asked Questions

Can a claimant sue an insurer for an unfair claims settlement practice?
Not under that article. Nothing in it “shall be construed to create or imply a private cause of action for a violation of this article” (OCGA 33-6-37); enforcement runs through the Commissioner of Insurance (OCGA 33-6-35).

Can a claimant get a copy of a recorded statement?
Georgia’s discovery statute lets a party obtain, without the special showing otherwise required, a statement about the action that the party previously made, and it lets a person who is not a party request a copy of that person’s own statement and move for a court order if the request is refused; a substantially verbatim recording or transcription counts as a statement (OCGA 9-11-26(b)(3)).

Can an adjuster’s offer be used as evidence at trial?
Except as OCGA 9-11-68 provides for offers of settlement, evidence of offering or accepting something of value to compromise a claim that was disputed as to validity or amount is not admissible to prove liability for the claim or its amount, and conduct or statements made in compromise negotiations or mediation are not admissible, subject to the statute’s exceptions, including evidence offered for another purpose such as proving a witness’s bias (OCGA 24-4-408).

Does the examined person get the examining doctor’s report, and what follows from asking for it?
On request, the party that caused the examination must deliver a detailed written report of the findings, test results, diagnoses, and conclusions, together with reports of earlier examinations of the same condition (OCGA 9-11-35(b)(1)). The other side may then request reports of any examination of the condition in issue, and by requesting and obtaining the report, the examined party waives any privilege as to the testimony of everyone who has examined, or later examines, that person for the same condition (OCGA 9-11-35(b)(2), (4)). These rules also apply to an examination by agreement unless the agreement expressly provides otherwise (OCGA 9-11-35(b)(5)).

  • OCGA 33-6-33 (improper claims settlement practice; threshold), 33-6-34 (unfair claims settlement practices), 33-6-35 (Commissioner’s hearing procedure), 33-6-37 (no private cause of action)
  • OCGA 9-11-35(a), (b)(1), (2), (4), (5) (physical and mental examination of parties)
  • OCGA 9-11-67.1(b)(1)(A), (g), (i)(1) (time-limited settlement offers, motor-vehicle collision claims)
  • OCGA 51-12-33 (apportionment of fault; 50 percent bar)
  • OCGA 33-4-6 (first-party bad-faith penalty)
  • OCGA 9-11-26(b)(3) (a person’s own prior statement)
  • OCGA 24-4-408 (compromises and offers to compromise)

Disclaimer

This article provides general information about how injury claims are handled in Georgia and is not legal advice. Claims practices vary by insurer and by the facts of each case. A person evaluating a claim or an insurer’s conduct should consult a licensed Georgia attorney about the particular situation.

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