Editor's note: updated July 2026 for New York's 2026 tort-reform changes.
Insurance companies evaluate car accident claims through a structured internal process. That process is not designed around what seems fair to the injured person. Understanding what the adjuster examines, what sets the reserve, and what moves the settlement number matters for anyone pursuing a claim in New York.
Early in his legal career, Steven worked on the defense side of accident cases. That experience gave him a clear view of how carriers evaluate claims from the inside. He saw what information drives the reserve, what arguments the carrier prepares, and where gaps in a claimant's case tend to matter most.
The reserve is set early and drives everything that follows
When a claim is reported, the carrier assigns an adjuster and sets an internal cost estimate called a reserve. The reserve is built from whatever information exists at that moment: the police report, early medical records, the accident type, and the reported injuries. It is not shared with the claimant.
The reserve matters because it controls the adjuster's settlement authority. The adjuster cannot offer more than the reserve without supervisor approval. When early information is incomplete, the reserve is often set low. That lower number becomes the starting point for every negotiation that follows.
Reserve-setting follows the carrier's internal rules and actuarial guides. An adjuster who sets a reserve too high gets questioned by supervisors. They want to know whether the case really justifies that level of risk. An adjuster who sets a reserve too low and then faces a large verdict also gets questioned. The question then is whether the case was valued properly.
That pressure pushes adjusters toward low opening reserves. Raising a reserve later is allowed, but it requires a reason. The reason has to come from new records or other facts the plaintiff's side puts in front of them.
This is why early documentation matters. A claim that arrives with a police report, scene photographs, a prompt ER visit, and consistent medical follow-up tends to draw a higher reserve. A bare-bones report and a two-week gap before the first medical visit tends to draw a lower one. The reserve adjusts as new information comes in. But the initial impression shapes how the carrier values the file from that point forward. Strong early documentation pushes reserves up. Weak early documentation produces low reserves that are hard to move later.
The adjuster evaluates liability first
Before the adjuster evaluates damages, the adjuster evaluates liability. Who was at fault? Is liability clear or disputed? How much fault can be placed on the claimant?
New York's comparative fault rules under CPLR 1411 govern the answer, but the standard depends on the type of case.
In premises liability and construction accident cases, pure comparative fault applies. A claimant's recovery is reduced by their share of fault, no matter how large that share is.
Motor vehicle cases work differently. New York's 2026 tort reform added CPLR 1411(b). For actions started on or after May 26, 2026, a claimant is barred from non-economic damages. That bar applies when the claimant's share of fault exceeds the combined fault of all defendants.
That rule changes how adjusters work auto files. The adjuster's focus is not just on reducing the claimant's share. The focus is on whether the claimant's fault can be pushed past that line entirely. Crossing it eliminates non-economic damages, not just reduces them.
In a non-auto matter, a 40% fault finding reduces the settlement value by 40% before the damages calculation begins. In an auto matter, the adjuster is working toward a different outcome altogether.
The adjuster pulls the police report, driver and witness statements, traffic camera footage, and physical damage photos. A rear-end collision or a documented red-light violation makes liability straightforward. A disputed lane change, a conflicting-account intersection crash, or a multi-vehicle pileup is different. The carrier discounts the claim's value because a jury might assign the claimant a share of fault. In a motor vehicle case, that matters more than it once did. Under CPLR § 1411(b), a claimant whose share of fault exceeds the combined fault of all defendants is barred from non-economic damages entirely. That rule applies to actions commenced on or after May 26, 2026. So the adjuster building a contributory negligence argument is not just negotiating. The adjuster is trying to move a number that could eliminate recovery altogether.
Every piece of evidence that supports the plaintiff's position raises the settlement value. Every piece that supports shared fault lowers it. Shifting the liability picture is one of the highest-value moves in case prep.
A $300,000 case with 30% fault on the plaintiff is worth $210,000. The same case with no fault on the plaintiff is worth $300,000. That $90,000 gap is what strong liability records are worth.
The serious injury threshold is the carrier’s first line of defense on damages
In every New York car accident claim, the carrier asks one damages question first. Do the claimant's injuries meet the serious injury threshold under Insurance Law § 5102(d)? If they do not, the carrier owes nothing beyond PIP benefits.
The carrier will have its own medical experts review the records. If the case is in litigation, it will also order an Independent Medical Examination. When the carrier's expert concludes the injuries fall short of the threshold, the carrier moves to dismiss on summary judgment.
This is not a formality. Threshold motions are filed routinely in serious New York car accident cases, and courts grant them in a meaningful percentage. A case built only on the injured person's subjective complaints, without objective medical findings, will be dismissed.
The treating physician's documentation has to establish the threshold with clinical precision from the first visit. That means range of motion measurements in degrees. It means neurological testing results, imaging findings, functional assessments, and causation opinions. Each element matters.
The carrier reviews that documentation carefully. It knows which cases have strong threshold evidence and which do not. That knowledge shapes every settlement offer it makes.
The carrier starts evaluating the serious injury threshold the moment the first medical records arrive. Treating physician notes with objective findings push the case toward the "likely survives" column. That shifts the carrier's analysis to damages. Records showing only subjective complaints push the case the other way. The carrier can then offer a low settlement, knowing a threshold motion may end the case before trial.
How the adjuster values pain and suffering
Once liability and the threshold are established, the adjuster turns to non-economic damages. There is no formula. The evaluation is a judgment call built on experience and data.
The adjuster looks at comparable verdicts and settlements in the same jurisdiction. Severity and permanence of the injuries matter. So does the claimant's age, the impact on daily life, and how credible the claimant would appear to a jury.
Some carriers run the claim through internal software. Colossus is the most widely known system. The adjuster enters data about the injuries and treatment, and the software generates a damages estimate. That estimate is not binding. It shapes the initial reserve and the adjuster's settlement authority, but it does not replace judgment.
Litigation risk is the carrier's estimate of what a jury might award if the case goes to trial. A case with clear liability, objective medical evidence, and a credible plaintiff raises that risk. Higher litigation risk pushes the carrier's settlement number up. Weak liability, thin medical records, or credibility problems lower it.
The plaintiff's attorney is part of that calculation. A firm with a trial record makes the carrier price in a real verdict. A firm known for settling every case does not carry the same weight.
What the carrier will not explain to you
The at-fault driver's adjuster will not remind you to file your NF-2 application within 30 days. The adjuster will not mention your own SUM coverage when the at-fault driver is underinsured. SUM, or supplementary uninsured/underinsured motorist coverage, is your own policy's backstop when the other driver's limits fall short. The adjuster will not explain the serious injury threshold or what medical evidence supports it. The adjuster will not suggest waiting to settle until your condition stabilizes and your damages are fully known. None of that is the adjuster's job. The adjuster's job is to evaluate and close the file. Advocating for you is your attorney's job.
Your own carrier's PIP adjuster works under a different set of rules. The no-fault statute requires the carrier to process your claim in good faith and pay benefits on time when the claim is supported.
That obligation stops at the no-fault file. Your PIP adjuster will not walk you through the serious injury threshold, SUM coverage, or a potential personal injury claim against the at-fault driver. Those issues sit outside the no-fault claim entirely.
The adjuster's job is to administer your no-fault benefits. Helping you understand the full picture of your recovery is not part of that job.
Coverage limits cap the recovery regardless of damages
The carrier cannot pay more than the policy limits. New York's minimum liability coverage is $25,000 per person and $50,000 per accident. Those figures are inadequate for any serious injury. If the at-fault driver carries only the minimum, the most that policy pays is $25,000, even when actual damages are far greater.
That gap is why identifying every available coverage source matters. The vehicle owner's policy may apply under VTL Section 388. An employer's policy may apply if the driver was working at the time. The injured person's own uninsured and supplementary uninsured motorist coverage, known as SUM, may also be available. Each source has to be located and evaluated before the full picture of available coverage is known.
The at-fault driver's adjuster will not hunt for extra coverage on your behalf. The adjuster works for the carrier. Their job is to evaluate the claim against that carrier's own policy. They do not search for other policies that could pay you more. Finding every available policy is your attorney's job. Miss one, and you leave money behind.
How Schwartzapfel Holbrook builds cases that change the carrier’s evaluation
At Schwartzapfel Holbrook, we build every car accident case to move the carrier's reserve and settlement authority upward. That means presenting complete medical evidence with objective clinical findings that support the serious injury threshold. It means developing the liability record so the comparative negligence argument carries as little weight as possible. It means identifying every applicable insurance policy so the available coverage is fully accounted for. And it means preparing the case for trial so the carrier's litigation risk assessment reflects a real verdict as a genuine possibility. The carrier evaluates every claim based on the evidence in the file and the attorney on the other side. We focus on both.
Schwartzapfel Holbrook / Fighting For You
