Specials, multipliers, and the words the statutes actually use

What is my claim worth? is the question this page exists to receive, and it is not going to answer it. Not as a figure, not as a range, not as an average, not as a rule of thumb dressed up as arithmetic. That refusal is not modesty. It is that the material anyone can actually open — statutes, regulations, supervisors’ own rules — contains a method, and in some markets a schedule, and nowhere a price for a particular person’s case.

What it does contain is a vocabulary. The confusion around this subject is a vocabulary problem in a numbers costume, so the terms come first, each in the words of the instrument that defined it.

The method with no author

The folk model arrives within a minute of searching. Add up the medical bills and the lost earnings — the specials — and apply a factor to that total to arrive at the figure for pain and suffering. The factor is said to be small for a minor injury, larger for a serious one.

Stated fairly, it has two virtues: it is arithmetic, and it is memorable. Its defect is harder to see. It has no author. Nothing in the Spanish valuation system, the English and Welsh tariff legislation, the Minnesota benefits statute or either unfair-claims instrument read here defines such a factor, sets its value, or describes the practice at all. Two legislatures have written an entire valuation method into law. Neither of them works this way. The pages that do publish a figure are, with striking consistency, pages selling representation.

Economic loss, from a statute that itemises it

Minnesota’s compulsory first-party benefits statute is useful here not because its limits travel — they do not — but because it defines each head of economic loss separately, with its own test.

Medical expense benefits are all reasonable expenses for necessary medical, surgical, dental, chiropractic and rehabilitative services, and for hospital, extended care and nursing — a list that runs on through prosthetic devices, prescription drugs, transportation and language translation. Two adjectives do the work, reasonable and necessary, and they attach to different things.

Income loss is loss of present and future gross income from inability to work proximately caused by the nonfatal injury. It expressly includes the costs a self-employed person incurs to hire substitute employees to perform tasks necessary to maintain the income, and expressly excludes income from substitute work actually performed, or that the injured person unreasonably failed to undertake — a duty hidden inside a definition.

Replacement services loss is a separate head with a test of its own: expenses reasonably incurred in obtaining usual and necessary substitute services in lieu of those the injured person would have performed not for income but for direct personal benefit or for the benefit of their household. The unpaid work someone can no longer do is not an afterthought to the wage claim; it is a different item with a different proof.

Spain sorts the same territory under two civil-law labels rather than a list: daño emergente — expense caused — and lucro cesante — earnings prevented — both under the patrimonial head, kept apart from the non-patrimonial ones.

Non-economic loss, in the two ways it has been written down

England and Wales gives it a name and little else: pain, suffering and loss of amenity. For whiplash injuries as the Civil Liability Act 2018 defines them, where the duration does not exceed, or is not likely to exceed, two years, that head is to be an amount specified in regulations made by the Lord Chancellor, graded by how long the injury lasted.

Spain instead decomposes it. The perjuicio personal básico for a temporary injury is the common loss suffered from the date of the accident until the end of the healing process or the stabilisation of the injury into a sequela, valued as a daily amount. On top of that sits loss of quality of life, which the statute defines as compensating the particular moral harm caused by the impediment or limitation that the injuries or their treatment produce in the person’s autonomy or personal development — in three grades, defined by what the person can no longer do, mutually exclusive, with a single grade assigned to each day.

Two terms carry the file. A secuela is a physical, intellectual, organic or sensory deficiency, or aesthetic harm, that derives from an injury and remains once the healing process has ended; a lesión temporal is what the person suffers until that process ends. Everything hangs off which side of that boundary a symptom falls on, and the boundary is drawn by a medical report conforming to the system’s rules, not by the author of the file.

The multiplier, which exists, and is not what you were told

Here is the finding this article turns on. The word multiplier does appear in statute — Spain’s system uses multiplicando and multiplicador explicitly — and what it means there has nothing in common with the folk model.

For loss of earning capacity following a sequela, the multiplicand is the injured person’s net income, or an estimate of the value of their work in the home, or of their capacity to earn. The multiplier is an actuarial coefficient produced by combining four things: any public permanent-incapacity pensions the person is entitled to, the duration of the loss, the risk of death given the degree of incapacity, and a discount rate that takes inflation into account. A parallel provision builds one for third-person assistance out of a comparable set of factors.

So: a coefficient applied to income, to price future income, built from actuarial factors and reduced by public benefits. Not a factor applied to medical bills to price suffering. The folk model borrowed a real word and pointed it at the wrong quantity.

What the reasoned offer has to show

Spain also settles what the injured person is owed by way of explanation. Within three months of the claim, the insurer must make a reasoned offer if it considers liability established and the loss quantified, or a reasoned reply if it does not.

A valid reasoned offer must value injury to persons and damage to property separately; must calculate the personal loss according to the criteria and amounts of Title IV and the Annex; must set out, itemised and in detail, the documents and reports relied on — including the final expert medical report — so that the injured person has the elements of judgement needed to decide whether to accept or reject; and must state that payment is not conditioned on waiving future actions. An offer that does not attach that report is not valid. A reasoned reply must say which of three things is missing — liability not established, loss not quantified, or some other cause, specified — and, where healing is still running, must commit to reporting every two months.

The principles behind that are the opposite of a lump sum. The system’s two stated foundations are full reparation and vertebración: patrimonial and non-patrimonial losses are valued separately, and within each, the several heads separately. Correct application, says another article, requires the criteria used to be justified, head by head.

What a supervisor requires the evaluation to rest on

Nothing read here tells an insurer what figure to reach. Several instruments tell it what the reaching has to look like.

Florida’s unfair-claim-settlement provisions make it an unfair practice to fail to adopt and implement standards for the proper investigation of claims; to deny claims without conducting reasonable investigations based upon available information; and to fail to promptly provide a reasonable explanation in writing of the basis in the policy, in relation to the facts or applicable law, for denial of a claim or for the offer of a compromise settlement. That last phrase is the one to keep: an explanation is owed for a low offer, not only for a refusal.

Minnesota’s claims-practices statute adds the file. It is an unfair practice to fail to include in the claim file all written communications and transactions emanating from, or received by, the insurer, as well as all notes and work papers relating to the claim. And no claim may be denied on the grounds of a specific policy provision, condition or exclusion unless reference to that provision is included in the denial.

None of that sets an amount. All of it is about whether the amount can be accounted for.

The reserve, and the software: two absences

Adjusters work with a reserve — the amount set aside on a file against its expected cost. We could not open a statute or supervisor’s rule defining it, so this article does not define it either.

The larger absence is the one readers ask about. We searched insurance supervisors’ own bulletin archives for material on bodily-injury claim evaluation software and on adjuster evaluation standards, and found nothing addressing it that we could open. There is secondary writing on the subject in abundance; none of it is a source this section will use. So the honest statement is the narrow one: we do not know, from anything we read, how such tools are used or supervised — and the conduct duties above apply to an evaluation whoever, or whatever, produced it.

What we cannot tell you

We cannot tell you what your claim is worth, and we would not if we could. We cannot give you a factor to apply to your bills, because none of the instruments read here contains one of the kind the question expects. We cannot tell you how either schedule would score a particular injury, because that is a medical determination made on a report, and this section describes claims processes rather than bodies. And the clock the insurer is working to — how long it has to respond or to decide — differs by market and sits in the jurisdiction notes below, as does the supervisor to whom a complaint about how an evaluation was handled is made.

Your own file, in these words

Sort what you have into the heads the instruments actually use, because that is the language an offer will come back in: expense caused, earnings prevented, unpaid work someone else now does, and — separately, never derived from the first three — the non-economic head your market names in its own way. Note the date the healing stopped or the injury stabilised, because that boundary decides which table anything falls under. Then read whatever offer arrives for the thing a statute is willing to demand on your behalf: not a figure you agree with, but an itemisation you can follow.

An amount that cannot be accounted for is not a valuation. It is a figure.