The term, "adjudication" is a formal way of saying, "deciding" or "resolving." The process that the insurance company goes through when deciding whether it owes you money or not is called "adjudication of a claim." It begins when someone submits a claim to the insurance company and requests reimbursement, such as for payment of a fence blown down in a windstorm. Claim adjudication is a relatively broad term used by different types of insurance providers including automobile, homeowner, workers' compensation and medical insurance carriers.
Insurance Claim Process
Injury to you or damage to your property triggers the adjudication process if you have insurance to cover the event. The first step involves notifying the insurance company of your claim. Once received, the company assigns the claim to a representative for evaluation. He will likely ask you to provide proof in the form of property estimates and medical bills. The claim usually remains open until you supply all the necessary proof. If you have a bodily injury case, this means your case most likely will not be settled until you finish medical treatment and your injury resolves. If your treatment does not match the expected pattern, the insurance company may require an evaluation of the claim by the doctors on the insurance staff to determine whether your medical care is inconsistent with your actual injury, or if you need the surgery recommended by your primary care provider. In some cases, if you do not agree with the settlement amount, you may sue in court.
- Cornell University Law School Legal Information Institute: Adjudication
- How does the insurance claims process work?
- New York State Workers Compensation Board: Understanding the Claims Process
- MB-Guide: Claims Adjudication Process - How Health Insurance Companies Process Claims
- Illinois Department of Insurance: Filing an Auto Claim with Another's Insurance Company
An attorney for more than 20 years, Cara O'Neill currently practices in the areas of civil litigation, family law and bankruptcy. She also served as an Administrative Law Judge and taught undergraduate and graduate courses in the areas of employment law, business law and criminal law for a well-known university. Attending the University of the Pacific, McGeorge School of Law, she graduated a National member of the Order of the Barristers - an honor society recognizing excellence in courtroom advocacy. She is currently licensed in the state of California.