How adjusters quietly shape the outcome before a lawyer is ever involved
Before a single pleading is filed, before experts are retained, and long before a jury is ever seated, a quiet but decisive voice is already shaping the trajectory of a medical malpractice case: the claims adjuster.
I know, because I used to be that voice.
As a former medical malpractice claims adjuster representing doctors and hospitals, I spent years evaluating potential exposure, controlling claim narratives, developing initial strategies, and carefully selecting the best defense counsel for the case. Now, as a plaintiff attorney, I advocate for the patients and families I once evaluated through the lens of adverse event trends, risk matrices, and loss reserves.
In a fictional example, an adjuster might have a new claim come in, “Jones.”
Who is “Jones”? To the adjuster, he is a 65-year-old retired male. He’s married. He sustained a surgical injury to his hand causing significant nerve damage. On paper, “Jones” seems like his allegations would be defensible about 65-70% of the time as a known risk and complication—maybe even higher if we got an expert to give us a strong opinion on causation, or lack thereof. “Jones” had a date of incident (DOI) of April 7, 2025. “Jones” had past medicals of $50,000. “Jones” was a smoker. Although it has nothing to do with the relative merits of the case, juries don’t like smokers, so the adjuster makes a mental note of it. The patient relations file indicates “Jones” was calm and likeable. He’d probably present well. However, “Mrs. Jones” was not happy at all with the explanation the surgeon had given her as to how the injury occurred to her husband. Perhaps she was prone to getting angry and could be presented in a way that made jurors think she was unreasonable.
Sadly, at the beginning of the claim cycle, most adjusters would never know that for the past two years “Jones” had been counting down the days to retirement so he could finally chase his dream of playing guitar in a classic rock cover band. The adjuster would also never know that “Jones” was a new grandfather and that after the surgical injury, he quietly avoided holding his newborn grandchild because he no longer trusted the strength in his hand. The adjuster would want to know these insights because, believe it or not, most adjusters do have a heart. Most good adjusters are good at their job because they are sympathetic and empathetic. Nonetheless, in the cold calculus of claims evaluation, “Jones” is often seen as a number, not as a person.
As I shifted sides, I came to understand that my perspective revealed a truth that few on the plaintiff side fully appreciate: that the claims adjuster is often the first, and most critical, gatekeeper to getting justice for injured persons like “Jones.” In this article, I’ll share with you how I analyzed those early, unseen stages of a claim, how I made decisions behind closed doors, and why a plaintiffattorney with an understanding of the internal claim management process gains a strategic edge. One disclaimer: these thoughts are my own. My ethics forbid me from disclosing any confidential or proprietary information.
The reserve whisper: why the first number matters more than you think
One of the most powerful, and least visible, levers the adjuster controls is the reserve, defined as the internal dollar figure set aside to account for the anticipated indemnity payout of a claim. While it may seem like just accounting, reserves drive everything: how much scrutiny a case gets, whether early resolution is even on the table, and, importantly, how much flexibility there will be to increase settlement funds down the road—if such an increase is merited.
In theory, reserves should reflect a sober assessment of liability and damages. In practice, adjusters often set reserves based on gut reactions, incomplete medical records, or worst-case-scenario thinking. The plaintiff’s attorney’s reputation, the judge, even recent verdicts and published settlements in the jurisdiction can all move the needle in one direction or the other. At conferences, I have overheard reserving conversations amongst adjusters such as, “How cute is the injured kid?” or “How gory was it when the artery was lacerated?” or “Do they have that one neurosurgery expert from Europe with the cool accent that the jury will love?” Adjusters are human. Sometimes, a senior adjuster with an ax to grind against a particular plaintiff firm will assign a particularly difficult-to-deal-with defense counsel, even if that defense counsel is unfavored by the insurance company. Other times, an adjuster may set a lower reserve than logic supports, effectively dooming any chance of early resolution. It’s supposed to be professional and not personal, but it doesn’t necessarily always work that way.
Geographic and political considerations also play a critical role. In Washington State, for example, adjusters are well aware that juries in King and Pierce County tend to return higher plaintiff verdicts than more conservative, rural areas. As a result, cases filed or likely to be venued in those jurisdictions may result in higher reserves from the outset than similar cases in Eastern Washington or smaller counties with defense-friendly reputations. The local jury pool, judicial track record, and even media sentiment can all weigh into the calculation.
Once the reserve is set, it becomes sticky. Adjusters don’t like to revise reserves upward unless something forces their hand, such as a damning deposition or a
persuasive expert report. A low initial reserve often creates an internal resistance to raising it, especially if it is being raised for purposes of settlement. The adjuster is essentially admitting to a miscalculation.
Early denial or early resolution: what drives the decision
Now, when I initiate claims in my role as a plaintiff attorney, many early denials feel arbitrary, cynical, or even hostile.But for an adjuster, early denials are often driven by a complex blend of institutional policy, strategic positioning, and sometimes, simple inattention.
Some healthcare systems and insurance carriers are philosophically opposed to early settlements. They fear it sends the wrong message, that the institution will be labeled as quick to pay and therefore be vulnerable to more claims and less meritorious claims. Other healthcare systems are more pragmatic: they understand that some cases will not get better with time, and early resolution may minimize costs and publicity.
In Washington, patient advocacy groups have long fought for both sides to operate from a simple premise, “treat injured patients as you’d want to be treated,” in the model of a Communication and Resolution Program. Unfortunately, this approach requires both sides to develop an agreed understanding of how to determine what is reasonable. That approach necessarily includes a lowering of weapons and an active de-escalation from both sides. This seldom occurs. From the defense perspective, it is difficult to admit negligence in a state with no damage caps, which is viewed as having the potential for unlimited financial exposure. From the plaintiff attorney’s side, we are duty bound to remember that, although systematic change over time is good, we have an immediate obligation to represent our client for their one and only case to best of our ability to achieve the best possible outcome as it is their sole opportunity for recovery.In almost every medical malpractice claims scenario, the adjuster is the one making the first read. The initial question the adjuster answers might be as broad as, “is this something?” Adjusters will often review medical records, incident reports, quality improvement materials, and sometimes even interview the clinical risk manager before a defense lawyer ever gets involved. That early assessment becomes the lens through which the entire case is viewed.
And here’s the unsettling part: many of these initial decisions are made without the benefit of expert review. External expert reviews require time and money. These are often luxuries an adjuster simply doesn’t have. Instead, adjusters use internal guidelines, prior claims experiences, internal reviews, and gut instinct to decide if a case should be fast-tracked for settlement or routed for a hard denial.
Crucially, adjusters don’t operate in a vacuum. Their decisions are heavily influenced. The “what, who, and how” of influencing those decisions varies widely from organization to organization. Clinical risk managers, physician leadership, and hospital administrators usually all play a role. Each of these groups has its own agenda, and often those agendas are to explain away the event rather than figure out what’s best for the organization and its injured patient. In addition, these stakeholder groups often have a relationship with the involved provider that can skew the objectivity of their review. With all these relationships, a plaintiff attorney gains valuable insight by knowing which department within an organization has the biggest influence on the claims program. It may be a hospital administrator whose primary concerns are institutional reputation, financial exposure, or politics. Alternatively, the involved physician may be a physician leader who is also a major revenue generator and strongly advocates for the claim against them to be defended as aggressively as possible.It’s also important to distinguish between third-party adjusters (“TPAs”) and in-house adjusters. TPAs work for insurance carriers that contract with hospitals and physician groups. They typically handle multiple accounts and follow their insurer’s overall risk philosophy, often driven by policy limits and reinsurance considerations. On the other hand, in-house adjusters are directly employed by the healthcare institution or its captive insurer. Their perspective is shaped not just by the potential financial exposure of a single claim, but also by institutional goals and long-term relationships with providers.
Large systems that are self-insured tend to have the most control over their claims, often taking a more aggressive approach to litigation because they are managing their own funds rather than relying on an external insurer. These entities can afford to take cases to trial as a deterrent strategy. Meanwhile, smaller hospitals or physician groups with more traditional insurance coverage often have less direct control over how claims are handled and may face greater pressure from their carriers to settle early if a case presents significant risk. The decision-making process for these cases can differ dramatically depending on who is controlling the purse strings.
Factors that tilt toward early denial include confident documentation by the provider, sympathetic facts for the defense, and a plaintiff firm known for dropping marginal cases. On the flip side, adjusters may recommend early settlement when they see a vulnerable plaintiff, poor documentation, or prior claim payouts on the involved provider. Most importantly, the more a plaintiff attorney establishes a track record of taking cases to trial, the more likely that attorney’s case will be given serious consideration for early resolution.
Flipping the script: strategic moves for plaintiff attorneys
Understanding the adjuster’s mindset isn’t just an academic exercise, it’s a true tactical advantage. The earlier you can influence the adjuster’s internal calculus, the better positioned you are to control the pace and value of the case.
My first recommendation would be to shape the story from day one. Adjusters are narrative-driven. Before they ever consult an expert, they build an internal story about what happened and why it matters. If your letter, notice of claim, or initial demand package lays out a compelling, credible, and emotionally resonant story, you’re giving them something powerful in which to anchor a strong reserve. This is a worthwhile exercise, even if the case doesn’t resolve
early. Don’t assume they’ll figure it out from a pile of records; they won’t. Include a concise medical summary, a timeline, and a clear articulation of damages. Use visual demonstratives early. Treat the adjuster like a decision-maker, because they are.
My second recommendation is to immediately advise of the strength of your case. If you’re waiting until discovery to “build your case” then you’re already behind. By the time of defense counsel’s initial report, the reserve is likely in place. Your early communications should aim to influence that number: include enough liability detail, demonstrative harm, and juror-sympathetic context to make an adjuster pause before assigning a low reserve.
My third recommendation is to understand the power of institutional politics. Not all cases are judged equally, even with the same facts. If a provider is a rainmaker, in a leadership role, or politically connected within the institution, expect more resistance. Likewise, if they’re a repeat offender or nearing retirement, the tone shifts. Know who your defendant is within the system, not just on paper. That context helps you anticipate how the case will be handled and how hard you’ll need to push. Be mindful and seek to file only meritorious cases, for which you are prepared to go to trial if necessary. The reputation of the plaintiff’s attorney matters—a lot.
Finally, make it easy for the adjuster to say yes. Adjusters are managing volume, personalities, and institutional pressure. The more organized, credible, and strategic your approach, the easier it is for them to justify a higher reserve or early settlement. Give them the ammunition they need: timelines, expert support, clear damages, and a sympathetic plaintiff who will connect with a jury. Building a good case is only part of the battle, it must also be packaged in a way that can be taken upstairs to the executives who make the big money decisions.
Full circle: a personal reflection
Leaving the defense side wasn’t just a career pivot for me, it was a philosophical one. As an adjuster, I was trained to see cases in terms of exposure, optics, and strategy. Now, I see the same cases in terms of harm, grief, and what it will take to make a family whole again.
People often ask what’s the biggest adjustment I’ve had to make after switching sides. There are many, but one in particular always comes to mind. When on the defense, it was my duty to defend every case to the best of my ability regardless
of my subjective beliefs on the merits of the case. As a plaintiff attorney, I have the opportunity to select cases at my discretion. This affords me the luxury of pursuing worthwhile matters, helping people, and sleeping well at night.
However, I haven’t abandoned what I learned on the other side. I use it every day. I know how adjusters think, how they talk to their supervisors, and what keeps them up at night. I know what moves the needle. I don’t see this knowledge as merely being my edge in any single case, but as part of my responsibility as I try to play my small role in driving institutional healthcare change in this country. If I can use my experience to help my clients get justice faster or prevent them from being steamrolled by bureaucracy and indifference, then the time I spent on the other side was valuable.
A version of this article was published in the May 2025 issue of Trial News