In the 1990s, some insurance companies started using computer programs, instead of individual judgment, to evaluate injury claims and to decide how much to pay to settle the claims.
These days, the transition to computerized systems is almost complete. Although they rely on them to different extents, virtually all insurance companies have some form of computerized injury claim evaluation system.
The first, and the most well-known, of these systems is Colossus.
In this article, I will explain what Colossus is, how it works and, most important of all, how to get the highest possible offer from Colossus.
What Is Colossus Injury Claim Evaluation Software
Colossus is a software program owned by Computer Science Corporation
(NYSE:CSC) which is licensed to individual insurance companies for use in evaluating bodily injury claims.
There are other similar programs that go by names such as Claims Outcome Advisor (“COA”), Injury Claims Evaluations (“ICE”) and Injury IQ.
Why do insurance companies use software programs to evaluate injury claims?
Well, certainly to simplify the claims settlement process and make it more consistent. However, those are secondary reasons.
The primary reason insurance companies use case evaluation software is to increase profits by reducing the size of auto claims payouts.
In fact, that is exactly what has happened since Colossus and other case evaluation software began being used in the 1990s. Payouts to injury victims have decreased. For example, according to A.M. Best, between 1995 and 2005, “the amount of money [Allstate] paid out per premium dollar in car accident cases declined from about 63 cents to 47 cents.”
It is believed that the main way that insurance companies use Colossus to reduce their payouts is that they are selective in putting information about prior claims – the data from which the evaluations are derived – into the system.
Because they are increasing insurance company profits, Colossus and its clones are not going anywhere any time soon. They are here to stay. So we have to deal with them.
How Colossus Works
The Colossus system is based primarily on information contained in the claimant’s medical records.
Insurance companies do not consider what you tell them, or even what you told your doctor in such things as office intake forms.
Instead, they rely on the diagnoses, treatments and other information reported in your medical records.
If your health care provider’s records are illegible, not clear or do not provide information in the form Colossus requires, the result is an evaluation that is lower than it would have been if the records had been better.
This is one reason why you always should thoroughly review your medical records after you get them and before you submit them to the insurance company.
An insurance adjuster goes through the medical records and then enters information into the Colossus system, prompted by a series of computer screens and questions. In a typical case, the adjuster answers about 40 questions, but in a complicated case there can be hundreds of questions to answer.
The Colossus evaluation system recognizes approximately 600 injuries and 10,000 injury valuation factors, which can range from the number of days in a hospital to the type of immobilization device used.
These are some things – sometimes called “value drivers” – that add value to cases in Colossus. Obviously, if these factors are present in your case, you must make sure your health care provider records them in her notes and that you point them out to the insurance adjuster when you make your claim.
CSC does not disclose information about how Colossus works. Neither do the individual insurance companies. To the contrary, they zealously protect it. However, through various sources, including former insurance company employees, we believe that the following factors influence Colossus evaluations:
- Whether you were taken to the hospital initially.
- Whether you had to stay in the hospital overnight.
- Your injuries. These are some of the injuries that Colossus recognizes and you should point out ALL that apply to your case:
- Herniated disc
- Neurological damage
- Crush, Extensive Soft Tissue, Degloving
- Soft-tissue, Whiplash
- Disc Injury
- Lacerating, Penetrating Injury
- Ligament, Tendon Damage
- Superficial Injuries
- Subluxation. A chiropractor’s diagnosis of subluxation is given less weight than an M.D.’s diagnosis of subluxation.
- Certain symptoms, or “complaints,” such as these:
- Muscle spasms
- Radiating pain
- Restriction of movement
- Vision impairment
- The type of treatment you received. Treatment by M.D.s is given more weight than treatment by a chiropractor. Chiropractor treatment is valued more highly if there was a referral from an M.D. Treatment by specialists such as orthopaedic surgeons and neurosurgeons is given more weight than treatment by family practitioners.
- The duration of treatment. Treatment for, say, 90 days puts the case in a particular category, but treatment for 91 days puts the case in an entirely different and more highly valued category. On the other hand, what is deemed excesive treatment, especially by chiropractors, does not add value to the claim.
- Whether you took medications.
- Whether you used medical aids such as walkers, crutches or neck collars.
- Use of TENS unit, home traction, home exercises.
- Whether there was a delay in starting treatment. If you did not start treatment for more than 2 weeks after your accident, this must be explained in your doctor’s records. An acceptable reason is that you were monitoring your situation to see if it resolved without treatment.
- Whether there were gaps in your treatment. If there were periods of, for example, more than 3 weeks without treatment, the value of your claim will be reduced.
- Your prognosis.
- Whether you have a permanent injury. If your doctor says you have a permanent injury, have the doctor do an evaluation under the AMA’s Guidelines to Permanency.
- Future medical bills if they are documented in your medical records.
- Aggravation of a pre-existing condition.
- “Duties under duress.” This means disability from such things as work,
domestic (inside the home) activities, household (outside the home) activities and educational/studies.
- Some seemingly irrelevant considerations, such as these:
- Substantial damage to your vehicle.
- Use of seatbelt.
- You had not been drinking.
Don’t forget that all of these things must be documented in your medical records to be considered.
How To Get The Highest Possible Colossus Valuation Of Your Claim
These are the things you must do to receive the highest possible evaluation of your claim from Colossus.
1. When you see your health care providers for treatment, be sure to report all complaints and problems so that they will be recorded in your medical records. Remember, to an insurance adjuster, if it is not in the medical records, it does not exist.
2. After you complete treatment, get copies of your medical records and review them thoroughly to make sure all important complaints, diagnoses, treatments, medications and your prognosis are included. If not, contact your health care provider and ask them to correct the error or omission. (They probably will not do so, but try.)
3. If your medical records do not contain all of the complaints, diagnoses, treatments, medications and your prognosis, ask your doctor to prepare a narrative report which includes these things:
- a. A detailed history of your injuries resulting from you car accident.
b. All subjective complaints that you made.
c. Detailed and specific diagnoses.
d. Detailed statement of all treatments, including the duration of each treatment.
e. The medical reason why each treatment was given.
f. All medications prescribed, including the amounts, the duration for which they were prescribed and the reason(s) they were prescribed.
g. A description of any pre-existing medical conditions or injuries which were aggravated by your accident, if any.
h. Your doctor’s medical opinion regarding the nature, extent and frequency of pain that your injury caused.
i. Any anticipate residual problems, and their anticipated duration.
j. Your prognosis. Whether you have any temporary or total disability impairments.
k. Whether any future medial treatment will be necessary. If so, what treatment and at what frequency. Also, what is the current cost of such treatment.
l. If you were disabled, the duration of your total disability. When did it end?
m. The duration of any partial disability. When did it end?
n. Physical limitations that you had as a result of your accident-caused injuries.
o. Any permanent injury.
p. Your doctor’s opinion on the question of whether your accident caused each of the complaints, symptoms and diagnoses.
There will probably be a charge for this report, but it will be money well spent if the report adds value to your claim.
4. The entire Colossus system is based on recoveries for an average case involving particular injuries. In any way you can, show the adjuster why your case is not average, but exceptional. That is, emphasize the seriousness of your injuries, the extensive treatment you received, the significant effects on your life, anything that makes your case exceptional.
5. Emphasize the most important factors, which to the insurance company are (a) the injuries and diagnoses, (b) whether there is permanent impairment and (c) whether you were disabled for any period of time.
6. Emphasize facts that prove your pain, such as reports of pain in the medical records and prescriptions for pain medication.
7. In your “settlement letter” or “demand letter” (two different names for the same thing), include references to where all of these factors appear in the medical records. Make it easy for the adjuster to find this information so it will be entered into Colossus.
If you do these things, you will get the best possible settlement offer from the Colossus system.
But, if you are not satisfied with that offer, don’t hesitate to take your case to court where a group of living, breathing, feeling people – a jury – will decide your case instead of a machine.
Jurors normally consider, and give great weight, to the very things Colossus does not even consider, the effect of an accident on a particular individual.