SAMPLE
DEMAND ONLY – DOES NOT REPRESENT POSSIBLE ALL DRIVERS
DEMAND
EXPERT PROGRAM WILL INDICATE WHICH DRIVERS YOU ARE
MISSING WHEN CREATING YOUR DEMAND LETTER FOR YOU. ALSO FORMAT OF LETTER IS SOMEWHAT LOST DUE TO BEING
CHANGED TO A WEB PAGE
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Copyright
@ 2003,
Law Offices of Jake
111
.
John Smith
Allfarm Insurance Company
1111
Claim Number: 55-5555-555
Your Insured: Bob
Brown
Date of Loss:
Our Client: Mrs.
Jane Doe
Dear John Smith:
This paragraph should introduce your client's
claim. Each of the paragraphs in this
sample demand can be as long or as short as you like. Use this area to identify all material
specifics of your client's claim which you feel will be useful to the adjuster
in supporting the documented medical findings.
This would be where your demand for settlement is stated and presented
to the adjuster. Include all such items
as severity of impact (i.e. side impact, total loss, DUI etc.). Also, include all other significant
information such as age, size and weight of your client, which would have
substance on accepting the duration and/or complexity of treatment regimen.
DOB:
Height: 5' 5" Weight:
125 lb
Medical Specials: $5,000.00 Income Loss: $5,000.000
Property Damage: $3,000.00
Date of first Treatment:
Injuries:
Contusion to Neck, Back, Chest, Left Shoulder, Left
Flank, Left Knee, Left Elbow
Liability:
In this paragraph you should discuss any significant
aspects of liability. However, if
liability is not disputed, a simple statement to that effect is
appropriate. In this section, be sure to
direct the adjuster to the numbered exhibit(s) containing supporting liability
documents. If the accident involved more
than one liable party, your comments concerning possible apportionment and any
other issues pertinent to multi-party claims should be included here.
ICD9 Injury Codes:
842.3 843.5
875.5 878.2 745.3
CPT Treatment Codes:
99205 99233
99255 99285 99263
99248 99251
Subsequent Injuries
Prior injury aggravation: Actively Treating
Subsequent:
In this paragraph you should discuss any prior injuries,
which occurred to your client prior to this accident date. It is significant whether the prior injury
was less or more than 24 months. It is also significant if treatment for the
prior injury was ongoing at the time this accident occurred. This would require some proration of the
medical specials as well as the general damages, which will be authorized for
settlement of their claim. If you have a
medical report from one of the treating physicians who sets this out be sure to
comment on it here. It is also important
to discuss any subsequent occurrence in this section. Explain any significance the subsequent
injury might or might not have on either the treatment or recovery period.
Neck and Back Injuries:
John
Smith, DC 59 05/01/ 2002 Complaints/treatment
recommended
Jane Frank, MD 3 05/01/2002 Complaints/treatment
recommended
Janice Back, DO 16 10/10/ 2002 Guarded
History of Complaints:
Range of Motion 6 to 12 months John Smith
Headaches 6 to 12 months John
Smith 03/022002
Spasms 1 to 3 months Jane Frank 02/022002
Radiating Pain 3 to 6 months John Smith 02/022002
TMJ 1 to 3 months John Smith 11/032002
Depression/Anxiety or TMJ additional notation
regarding treatment:
In this section be sure to discuss the TMJ complaints
found in any treating records of any provider.
This would include a complaint of grinding of teeth without treatment
provided. Describe if there was any
treatment provided to resolve this complaint.
Treatment could include change of diet, splint therapy, surgery or
simply the wearing of a guard during the patient's sleeping hours.
Also, be sure to discuss any diagnosis of depression
or anxiety as recorded in the records.
There must be some form of treatment provided to relieve these
complaints in order for the complaint to be accepted and paid for by the
insurer. However, this treatment could
be as simple as rest, directions to avoid certain activity or circumstances
and/or even exercise might in some circumstances qualify. Be sure to identify the last medical record
where these are indicated and the duration of the complaint. Even if there is no treatment, still indicate
the last chart note where the complaint is documented.
Other Injuries:
Chest Contusion Jane Frank 02/022002 3 to 6
months Undetermined
With Complications
Left Flank John Mandible
Left Knee Mary Runing
04/022002 6 to 12 months Complaints/treatment recommended
Complications:
Pulmonary embolism John Brand 04/022002
Delayed wound healing Joe Blow
Delayed bony union John Smith
Non-union Paul
Joiner
See Dental and Orthodontic records provided in Medical
Billings Tab. Also see reports from Dr.
Mouth and Dr. Hand.
John Mouth 15 05/012002 10/192002 3,400.00
Paul Hand 6 01/15/2002 04/15/2002 5,000.00
Future dental treatment costs: $8,400.00.
History of Treatment:
Hospitalization # of Times: Dates: Days:
16 ICU: Yes
2 04/15/2002
and
Confined
to Bed Duration: Physician: Chart
Date:
3
weeks Janet Hand
Immobilization Duration: Type: Physician: Chart Date
3
weeks Corset John Hand
Injections Type Number Physician Chart Date
Cortico-Steroid 1 Jane
Frank
Tens at home Duration Physician Chart Date
Weeks 4 Jane
Frank
Physical Therapy: Duration: Times
per week Last Date
Prolonged 3 12/12/2002
Self-Exercise: Duration: Physician Chart Date
Prolonged Jane Frank
Procedure Result Physician Date
MRI Positive
John Hand
X-ray Positive Frank Notice
CAT scan Negative Joyce
Campbell
Medication Duration: Physician Chart
Date
Short John Brown
Impairment Whole Body
12% John
Brown
Loss of Enjoyment Domestic Jane Frank
Hobbies Jane Frank
Duties under Duress Household Physician Chart Date
Jane Frank
Number of Children Ages: Assistance
Three 5,
10, 13 Unpaid
Discussion of Future losses:
In this section, discuss your opinions, which are
documented by chart note or medical report.
Be specific as to the dollar amount and type of treatment being
recommended. This would include scar
revision or other disfigurement, which would require future medical
treatment. It is understood if the
future treatment is an estimate. If
there is scar revision being recommended, it is always helpful to include
photographs. It is acceptable to include
the estimate of another specialist for these procedures.
Be sure to indicate the likelihood that this future
cost will occur, i.e. less than 50% chance, greater than 50% chance, or greater
than 75% chance. If there is a scar
revision required at some later date, be sure to have a prospective cost
analysis provided. If there is future
surgery, be sure to include all recovery treatment costs as well, (i.e. cast
removal, pin removal, physical therapy, self exercise...) If there is future
loss of income expected, discuss it here.
Also, include any rehabilitative therapy, which would also be
recommended as a result of the expected surgery.
Jane Brown
John Carver
Future Medical Costs:
Amount: $ Type: Physician Chart Date
3,000.00 chiropractic Jane Frank 12/022001
8,400.00 Orthodontic Mouth/Hand
Future Income Loss:
550.00 Full time Jane Frank 12/022001
Total Medical Costs (Current
and Future) $16,400.00
Total Income Loss (Current and Future) $ 5,550.00
Total Special Damages
(Current and Future) $21,550.00
This section should pull all the points of the other
paragraphs together in a very brief summary. If there were particular points
needed to be emphasized so as to allow some of the entries in this format you
made on behalf of your client, make those here. It would be appropriate to
restate your settlement demand in this paragraph along with any time restrictions
being required by you. Your client's claim is being compiled in a
way so as to maximize the value. Don’t restate the issues you have discussed
in the preceding paragraphs in any great detail. If you feel there is additional information,
which should be provided, go to that section and add the details to that
paragraph. Be polite and available to
discuss additional documentation needed
Sincerely,
Jack Attorney
Cc: Mrs. Jane
Doe
Attached:
Exhibit
A: Property damage
Exhibit
B: Medical Records and
Exhibit
C: Medical Reports
Exhibit
D: Employer Records