Medical Treatment Gaps in Texas Injury Claims

What to Do When the Insurance Company Uses Gaps Against You

If you’ve been in an accident and the at-fault insurance company tells you that a gap in your medical treatment is a problem for your claim, it’s natural to feel concerned. They might even suggest that your injuries aren’t serious or use the gap as a reason to offer a low settlement. While this situation can be stressful, all hope is not lost. There are legitimate reasons for treatment gaps; you have ways to explain them and fight for fair compensation.

In this post, we’ll break down what medical treatment gaps are, how they impact your injury claim in Texas, and – most importantly – what steps you can take to protect yourself and still get the settlement you deserve.

What Is a Medical Treatment Gap, and Why Does It Matter?

A treatment gap refers to any period after your accident where you didn’t receive medical care for your injuries. For example, you might have seen a doctor right after the accident but didn’t go back for follow-up visits for weeks or months. These breaks are common, but insurance companies can use them to argue that your injuries aren’t as serious as you claim.

Their logic goes something like this: “If you were really injured, you would have gone to the doctor consistently.” This thinking allows them to reduce the value of your claim or offer a lower settlement, but that’s not the full picture. People experience gaps in treatment for all sorts of reasons, and you have the right to explain them.

Let’s dive into how these gaps can impact your claim and, more importantly, what you can do about it.

How Gaps in Treatment Reduce Settlement Amounts

When an insurance adjuster sees a gap in your medical treatment, they often use it to lower your settlement offer. They might argue:

• You weren’t as injured as you say because you didn’t continue treatment.
• Your injury wasn’t caused by the accident, especially if you waited a long time before getting treated.
• They should reduce the payout for pain and suffering since your lack of treatment suggests a quick recovery.

This can be frustrating, especially if there were valid reasons for the treatment gap. Don’t let this tactic scare you. You can explain the gap with the right approach and still pursue fair compensation.

Why Do Treatment Gaps Happen?

There are many reasons why people delay or pause medical treatment. Life is complicated, and your circumstances may have prevented you from following your doctor’s recommended treatment plan. Here are some common reasons:

1. Financial Barriers: Many people can’t afford ongoing medical care, especially if they don’t have insurance or face high out-of-pocket costs. This is a reality for many injury victims.
2. Feeling Better: Sometimes, after a few treatments, you might have felt like your condition was improving and stopped seeing your doctor. Unfortunately, injuries can flare up again or worsen over time.
3. Delayed Diagnosis: Some injuries, like whiplash or concussions, don’t show symptoms immediately. You might not have realized how serious your injury was until weeks or even months later.
4. Access to Healthcare: Getting to a doctor isn’t always easy. In rural areas, or if you have limited transportation, finding a specialist or getting follow-up care can be challenging.
5. Unrelated Illnesses: Sometimes, you might have an unrelated illness that causes you to miss or delay treatments. If you caught the flu or developed another health issue that took priority over your injury treatment, that can also explain the gap. If this applies to you, it’s important to document it.
6. Working Through Pain: Many people continue their daily responsibilities, like work or family obligations, even after an accident. You might have delayed treatment, hoping that your pain would go away on its own. This is common, and it’s important to explain to the insurance company if this is the reason for the gap.

These are all valid reasons for a treatment gap, and they don’t mean your claim should be dismissed. The key is to prove continuity of care despite the gaps.

How to Explain Treatment Gaps and Prove Continuity of Care

If the insurance company is using a treatment gap against you, there are steps you can take to explain the situation and prove your injuries are still valid. Here’s what you can do:

1. Gather Detailed Medical Documentation

Your medical records are one of the most important tools you have to show that your injury is real, even if you took a break in treatment. These records should show:

• Your initial diagnosis and any follow-up treatments.
• The timeline of your care, including when you resumed treatment after the gap.
• An explanation of why there was a delay in care (if your doctor can provide one).

2. Get a Written Explanation from Your Doctor

If you can, ask your doctor to write a statement that explains why your treatment was delayed or paused. Maybe you were waiting to see if your symptoms improved, or maybe you had financial challenges that made it difficult to continue care. A written explanation can go a long way in justifying the gap.

3. Consider Expert Testimony

If the insurance company is really pushing back on the treatment gap, expert testimony can help. A medical expert can testify that your injury timeline is consistent with your diagnosis and that gaps in treatment don’t reduce the seriousness of your injury. This can be especially helpful when it comes to negotiating a settlement.

Supplement Your Medical Records with a Symptom Journal

Another way to prove continuity of care is by keeping a symptom journal. This allows you to document your pain, discomfort, and limitations on a daily basis, even if you’re not currently receiving treatment. Here’s what you should include in your journal:

• Your pain level each day, rating it from mild to severe.
• How your injury affects your ability to work, take care of family responsibilities, or go about daily activities.
• Any symptoms that develop or worsen over time.

This journal can be especially useful if there are gaps between doctor visits. It provides extra evidence that your injury continues to affect you, even when you aren’t actively seeing a doctor.

Pre-existing Conditions and Treatment Gaps

Another tactic insurance companies use when they see gaps in treatment is to blame your injuries on pre-existing conditions. They might argue that your injury wasn’t caused by the accident at all but by something that existed before it. This can be especially problematic if your medical history includes conditions similar to the injuries you’re claiming.

How to Address Pre-existing Conditions

Even if you had a pre-existing condition, you are still entitled to compensation if the accident worsened that condition. Here’s how to deal with this:

• Medical Documentation: Make sure your records clearly show how the accident worsened your condition. For example, if you had a back injury before the accident, your records should show how the crash aggravated that injury.
• Physician’s Explanation: Ask your doctor to provide a written statement clarifying how the accident impacted your pre-existing condition. This can be crucial in proving that your injuries are related to the accident, not just your medical history.
• Expert Testimony: A medical expert can testify that the accident worsened your condition, helping to overcome any arguments from the insurance company.

Even with pre-existing conditions, you can still recover compensation if you show that the accident contributed to or aggravated your injury.

Why Continuity of Care Matters

Continuity of care simply means staying on top of your medical treatment after an injury. This includes seeing your doctor regularly, following their recommendations, and keeping up with any prescribed therapy or tests. Insurance companies look at your medical history to see if there’s a clear, consistent record showing your injury is related to the accident.

When there are treatment gaps, it can disrupt that consistency. The insurance company might argue that your injury wasn’t caused by the accident or that it’s not as serious as you say. For example, if you wait too long to seek treatment or take long breaks between appointments, they could claim your injury happened later or wasn’t that bad to begin with.

Why It’s Important for Your Claim

When you follow through with your medical care:

• Causation is clearer: It’s easier to prove your injury is directly connected to the accident.
• Injury severity is documented: Consistent treatment shows how serious your injury is and how it impacts your life.
• You’re showing effort to recover: Sticking with your doctor’s plan shows you’re serious about getting better.

What Happens When There’s a Gap?

If there’s a break in your treatment, it can hurt your case. The insurance company might argue that:

• Your injury isn’t related to the accident.
• You’re exaggerating how bad your injury is.
• You’ve already recovered, so you don’t need more compensation.

How to Get Back on Track After a Gap

Even if there’s been a gap in your care, you can still rebuild your case:

1. Get back to treatment: Start seeing your doctor again as soon as possible.
2. Explain the gap: Whether it was due to finances, health issues, or something else, have your doctor explain why you stopped.
3. Document everything: Use a symptom journal to show how your injury affected you during the gap, even if you weren’t receiving treatment.

Why Continuity Fits into the Bigger Picture

The bottom line is this: consistent medical care makes it easier to prove your injury and fight for fair compensation. Treatment gaps give the insurance company room to argue against you, but with the right steps, you can close those gaps and still build a strong case.

Financial Barriers: A Common Reason for Treatment Gaps

One of the most common reasons people delay treatment is because of financial hardship. Without insurance or with high medical costs, it can be impossible to continue seeing doctors or specialists. But just because you couldn’t afford care doesn’t mean your injury wasn’t serious.

How to Prove Financial Barriers

Your lawyer can help you show that financial hardship was the reason for the gap by:

• Providing proof of your financial situation, such as bank statements, income records, or medical bills.
• Showing that you resumed treatment as soon as you could afford it.
• Using medical liens, where healthcare providers agree to get paid out of your settlement, to show you made efforts to get care.

By presenting this information, you can explain the delay and show that your injury deserves full compensation.

Insurance Company Tactics Regarding Treatment Gaps

Insurance adjusters are trained to minimize claim payouts, and gaps in treatment give them an opening to do just that. Their common tactics include:

• Arguing that gaps in care mean your injury wasn’t serious.
• Suggesting that your injury was caused by something else that happened during the treatment gap.
• Reducing compensation for pain and suffering, claiming that the gap shows you recovered more quickly than claimed.

These tactics are designed to lower your settlement, but they can be countered. A personal injury lawyer can help you gather evidence, explain the treatment gap, and negotiate a fair settlement.

When to Get a Lawyer Involved

If the insurance company has brought up the treatment gap as a reason to lower your settlement or deny your claim, now is the time to get legal help. An experienced attorney will know how to deal with these tactics, gather the right medical records, and present your case to maximize your compensation.

Here’s how a lawyer can help:

• Organizing medical records to show consistent care.
• Communicating directly with the insurance company to address their concerns about the treatment gap.
• Negotiating a fair settlement that takes into account the full extent of your injuries, even with a treatment gap.

Explaining Treatment Gaps to the Insurance Company

When explaining a treatment gap to the insurance company, it’s important to be direct and clear. Don’t wait for them to bring it up – address it head-on. Here’s how:

1. Explain Why the Gap Happened: Be upfront about the reason for the delay, whether financial, logistical, or personal. Let them know if you were waiting for symptoms to develop or improve.
2. Provide Evidence: Back up your explanation with medical records, proof of financial hardship, or even a statement from your doctor.
3. Use Expert Testimony if Needed: If your case is complex, consider having a medical expert explain that the gap doesn’t reduce the seriousness of your injury.

Take Control of Your Claim and Protect Your Settlement

Don’t be discouraged if you’ve been told that a gap in your medical treatment is hurting your injury claim. Treatment gaps are common, and they can be explained. The key is to act now – gather your records, work with your doctor, and get legal help if necessary.

At Genthe Law Firm, we understand the challenges of navigating treatment gaps and dealing with insurance companies. Our team is ready to help you build a strong case and help get you the fair compensation you deserve, even if there have been breaks in your care. Give us a call at 214-957-0898.