How Insurance Adjusters Use Treatment Gaps to Reduce PI Settlements

Insurance adjusters look for treatment gaps in personal injury cases because gaps give them leverage to reduce settlement offers by 20-40% or more. A gap in treatment — any period of 14+ days without medical appointments — allows adjusters to argue that injuries weren’t severe, the client recovered, or current complaints aren’t accident-related. Understanding how adjusters weaponize these gaps helps PI attorneys prevent them before they damage case value.

What Is a Gap in Treatment in Personal Injury Law?

A gap in treatment is any interruption in medical care lasting 14 days or longer without documented medical justification.

What counts as a gap:

Client misses 2+ consecutive physical therapy appointments (typically 14+ days)
Client stops attending scheduled follow-ups with treating physician
Client delays seeking treatment after initial ER visit (30+ days)
Client discontinues prescribed treatment without medical approval

What doesn’t count as a gap:

Doctor advises rest period or pause in treatment (documented in medical records)
Client is hospitalized or has emergency medical issue preventing appointments
Medical provider cancels or reschedules appointments
Client completes prescribed treatment course and is discharged

The key distinction: Insurance adjusters only care about unexplained gaps. If there’s a documented medical reason in the records, the gap doesn’t hurt the case. If there’s no documentation explaining why treatment stopped, the adjuster will use it aggressively.

The Insurance Adjuster’s Playbook for Treatment Gaps

When an adjuster reviews your demand package and sees treatment gaps, here’s exactly what they do:

1. They Question Injury Severity

Adjuster argument: “If the injuries were as serious as claimed, the client would have attended every appointment. The fact that they missed multiple PT sessions over 6 weeks suggests the pain wasn’t severe enough to prioritize treatment.”

What they’re really doing: Using the gap to dispute your pain and suffering multiplier. If they can argue the injury was minor or moderate instead of severe, they reduce the settlement offer by $15,000 to $40,000.

2. They Dispute Causation

Adjuster argument: “The 4-week gap in treatment indicates the client recovered from the accident. Current complaints about back pain are likely unrelated to the original incident or are pre-existing conditions that worsened independently.”

What they’re really doing: Breaking the causal chain between the accident and ongoing symptoms. If they can argue the client recovered during the gap, they don’t have to pay for treatment that happened after the gap.

3. They Reduce Future Medical Coverage

Adjuster argument: “The client’s inconsistent treatment demonstrates they don’t actually need ongoing care. We’ll cover past medical bills up to the gap, but we’re not including future treatment costs in the settlement.”

What they’re really doing: Eliminating future medical damages from the settlement calculation. This can cost your client $10,000 to $50,000+ depending on projected treatment needs.

4. They Attack Credibility

Adjuster argument: “The client claims they’re in constant pain, but they didn’t go to physical therapy for three weeks. That inconsistency suggests exaggeration. A jury will see this gap and question everything the plaintiff says.”

What they’re really doing: Framing the entire case as suspicious. Once they plant the “exaggeration” seed, every other claim (lost wages, emotional distress, disability) becomes easier to dispute.

5. They Lower the Initial Offer Dramatically

Adjuster calculation without gaps:

Medical bills: $18,000
Lost wages: $6,000
Pain and suffering (3x multiplier): $54,000
Total demand: $78,000
Initial offer: $55,000 – $65,000

Adjuster calculation with a 3-week gap:

Medical bills: $18,000
Lost wages: $6,000
Pain and suffering (1.5x multiplier due to “questionable severity”): $27,000
Total demand: $51,000
Initial offer: $30,000 – $38,000

The gap cost your client $20,000 to $35,000 in settlement value.

How Long of a Gap Is Too Long?

14-21 days (2-3 weeks):

Adjuster will mention it and use it to shave 10-15% off the offer
Still negotiable if you have strong liability and damages elsewhere
Can sometimes be explained away with work conflicts or scheduling issues

22-30 days (3-4 weeks):

Significant leverage for the adjuster
Reduces settlement value by 20-30%
Harder to explain without documented justification
Shifts negotiation focus to the gap instead of defendant’s liability

30+ days (1+ months):

Devastating to case value
Adjuster will argue client recovered during gap
Settlement offers drop 30-50% or more
May trigger lowball offers that force litigation
Extremely difficult to recover full value even with strong liability

Multiple gaps (regardless of length):

Pattern of non-compliance
Adjuster frames client as unreliable or exaggerating
Case value drops 40-60%
High risk of needing to litigate to get reasonable settlement

Real Examples: What Adjusters Say About Treatment Gaps

Example 1: Soft Tissue Injury with 3-Week PT Gap

Adjuster email: “We’ve reviewed the demand package. Our insured accepts liability for the rear-end collision. However, we note your client missed physical therapy from March 15 through April 8 — a 24-day gap. This suggests the injury resolved during that period. We’re offering $8,500 to close this claim, covering initial treatment only.”

Translation: They’re offering 40% of your demand because the gap lets them argue recovery.

Example 2: Moderate Injury with Multiple Small Gaps

Adjuster email: “Your client’s treatment timeline shows inconsistent attendance: missed appointments on 2/10, 2/24, 3/3, and 3/17. This pattern raises questions about injury severity and client credibility. We’re valuing pain and suffering at 1.5x specials, not the 3x you’ve requested. Our offer is $22,000.”

Translation: Multiple small gaps create a “non-compliance pattern” they use to slash the multiplier.

Example 3: Serious Injury with One Explained Gap

Adjuster email: “We see a 3-week gap in treatment from January 10-31. However, medical records indicate your client was hospitalized for an unrelated infection during that time. Since this gap is medically justified, we’re not reducing our evaluation. Our offer is $78,000.”

Translation: Documented gaps don’t hurt you. Only unexplained gaps give adjusters leverage.

How Insurance Companies Train Adjusters to Find Gaps

Insurance companies specifically train adjusters to:

Review medical chronologies for date gaps — They use software that flags any 14+ day period without appointments
Cross-reference treatment dates with client statements — Looking for inconsistencies between “constant pain” claims and missed PT
Compare treatment frequency early vs. late in timeline — If client went 3x/week initially then dropped to 1x/month, they argue improvement
Check for gaps between accident date and first treatment — Delays in seeking care suggest injury wasn’t serious
Look for abandoned treatment plans — Client prescribed 12 PT sessions but only attended 6

The adjuster’s internal checklist:

✓ Any gaps of 14+ days? (Flag for reduction)
✓ Multiple gaps? (Argue pattern of non-compliance)
✓ Gap followed by new complaint? (Argue unrelated condition)
✓ Client stopped treatment before discharge? (Argue recovery)
✓ Treatment frequency declined over time? (Argue improvement)

Every single one of these is a reason to reduce the offer.

What Insurance Won’t Tell You About Treatment Gaps

Secret 1: Adjusters care more about gaps than total treatment cost

A case with $25,000 in medical bills and no gaps will settle for more than a case with $35,000 in bills and three gaps. Consistency matters more than volume.

Secret 2: They’re hoping you don’t address the gaps in your demand

If you don’t proactively explain gaps in your demand letter, the adjuster assumes you’re hoping they won’t notice. This makes them more aggressive in using gaps against you.

Secret 3: Even small gaps give them negotiating room

A 10-day gap isn’t technically a “treatment gap” by insurance standards — but adjusters will still mention it to justify a lower offer. They’re trained to find any weakness.

Secret 4: They use gaps to delay settlement

If an adjuster can point to treatment gaps, they can justify “waiting to see if the client re-injures” or “needing more medical records to explain the interruption.” This delays settlement by months, pressuring clients to accept lowball offers.

How to Protect Your Cases From Gap-Based Reductions

1. Prevent gaps before they happen

The best defense is no gaps at all. Proactive client follow-up throughout treatment catches problems (transportation, pain, overwhelm) before appointments are missed.

2. Document every gap immediately

If a client misses an appointment, document:

Why they missed it
When they rescheduled
Any barriers they’re facing (transportation, work, pain)

Get this information into medical records or your case file the same day.

3. Address gaps directly in your demand letter

Don’t ignore gaps and hope the adjuster misses them. Explain every gap proactively:

“You’ll note a 16-day gap in PT from March 3-19. During this period, Mr. Johnson was unable to secure transportation to appointments due to his vehicle being in the repair shop following the collision. He resumed treatment immediately once transportation was arranged.”

4. Get treating physicians to document justified gaps

If a client needs to pause treatment for medical reasons, get the doctor to document it:

“Patient advised to rest and avoid PT for two weeks due to acute pain flare. Will resume therapy once inflammation subsides.”

This removes all adjuster leverage.

5. Use gaps as proof of real injury

Sometimes you can flip the script: “My client pushed through excruciating pain to attend 18 of 20 PT sessions despite transportation difficulties and work obligations. The two gaps you’re citing actually demonstrate how seriously she took her recovery.”

How FileFlow Prevents Treatment Gaps Before Insurance Can Use Them

FileFlow’s AI case assistant, Samantha, eliminates treatment gaps by:

Calling clients 24 hours before every appointment to confirm attendance
Flagging transportation or pain issues to your team before appointments are missed
Following up within hours of no-shows to reschedule immediately
Tracking symptoms and recovery progress so you know when clients are struggling
Documenting every interaction automatically so gaps are always explained in real-time

The result: Adjusters have nothing to work with. Your treatment timelines are clean, consistent, and fully documented — which means higher settlement values and faster closures.

Common Questions About Treatment Gaps and Insurance

Do insurance adjusters always reduce offers for treatment gaps?

Yes, if the gaps are unexplained. Adjusters are trained to find gaps and use them to reduce settlement value. Even small gaps (10-14 days) give them room to negotiate lower. The only gaps that don’t hurt you are those with clear medical documentation explaining the interruption.

How much does a treatment gap reduce a personal injury settlement?

A single 2-3 week gap typically reduces settlement value by 10-20%. Gaps of 4+ weeks can reduce offers by 30-50%. Multiple gaps often result in 40-60% reductions. The exact impact depends on injury severity, liability strength, and how well you can explain the gaps.

Can I still get a good settlement with gaps in treatment?

Yes, but you’ll need strong liability, clear causation documentation, and proactive explanations for every gap in your demand letter. Cases with gaps always settle for less than cases without gaps — but you can minimize damage by addressing gaps head-on and having medical justification when possible.

What do I say when an adjuster brings up a treatment gap?

Address it directly: explain why the gap happened (transportation, work conflict, medical reason), show that the client rescheduled promptly, and emphasize that treatment resumed without any indication of recovery. If the gap was medically justified, reference the doctor’s notes. Never ignore the gap or get defensive.

How do I explain a gap in treatment in my demand letter?

Be proactive and factual: “You’ll note a 3-week interruption in physical therapy from [dates]. During this period, the client was unable to attend appointments due to [specific reason: transportation, work obligation, medical issue]. Treatment resumed on [date] with no change in symptom severity, as documented in the medical records.”

What if my client has multiple treatment gaps?

Multiple gaps are harder to defend but not impossible. Document the reason for each gap, show that the client consistently rescheduled and resumed treatment, and emphasize any external barriers (transportation, work, childcare). Consider getting a treating physician to write a letter explaining that gaps don’t indicate recovery.

Do adjusters care about gaps between the accident and first treatment?

Absolutely. Delays in seeking initial treatment (especially 7+ days after the accident) give adjusters leverage to argue the injury wasn’t serious or isn’t causally related to the accident. Always advise clients to seek medical attention within 72 hours of any accident.

How can I prevent treatment gaps in my PI cases?

Prevent gaps with proactive client communication: confirm appointments 24 hours in advance, verify transportation, follow up immediately on no-shows, and help clients solve barriers (pain, scheduling, rides) before they miss appointments. Firms using automated follow-up systems see 40-60% fewer treatment gaps.

The Bottom Line on Insurance and Treatment Gaps

Insurance adjusters are trained to find treatment gaps and use them aggressively to reduce settlement offers. A single unexplained gap of 3-4 weeks can cost your client $15,000 to $30,000 in settlement value. Multiple gaps can cut offers in half.

The only way to protect case value is to prevent gaps before they happen — not explain them after the damage is done.

Want to see how FileFlow prevents treatment gaps before insurance can use them?
Book a 10-minute demo: [Link to demo]