The True Cost of Treatment Gaps: How They Reduce PI Case Value

A three-week gap in treatment can cost your client 30-60% of their settlement value. Adjusters know this—and they're trained to find these gaps and exploit them.

Treatment gaps are one of the most common ways PI attorneys unknowingly leave money on the table. Understanding why gaps hurt and how to address them is essential for maximizing case value.

What Is a Treatment Gap?

A treatment gap is any period where a plaintiff stops seeking medical care after an injury. It's the space between appointments that insurers use to argue the plaintiff wasn't really hurt—or that their injuries resolved.

How adjusters define gaps:

The clock starts at the last appointment. If your client saw their doctor on January 15th and didn't return until March 1st, that's a 45-day gap—regardless of what happened in between.

Why Adjusters Exploit Treatment Gaps

Insurance adjusters aren't being unreasonable when they flag gaps. They're following a logical argument that juries find persuasive:

The adjuster's argument:

"If the plaintiff was really in pain, they would have sought treatment. The gap in care proves their injuries weren't as severe as claimed—or that they had recovered by the time they stopped treating."

This argument works because it appeals to common sense. Most people, when experiencing significant pain, do seek help. The absence of treatment suggests the absence of suffering.

What adjusters conclude from gaps:

1. Injuries resolved — Pain went away, so treatment stopped
2. Not that serious — If it was bad, they'd have gone back
3. Caused by something else — Something happened during the gap
4. Plaintiff not credible — They claim ongoing pain but didn't treat

Each conclusion reduces case value. Combined, they can devastate it.

The Financial Impact of Treatment Gaps

Treatment gaps don't just weaken your case—they reduce settlement value dramatically.

Typical value reduction by gap length:

A $100,000 case with a 60-day treatment gap might settle for $40,000-$60,000. The gap doesn't just affect pain and suffering—it undermines the entire damages picture.

Why gaps compound:

• Adjusters apply gap discounts to non-economic damages first
• Then they question whether all medical treatment was necessary
• Finally, they argue future medical projections are inflated
• Each reduction builds on the previous one

Common Reasons for Treatment Gaps

Understanding why gaps happen helps you address them. Most gaps fall into predictable categories.

Financial Barriers

The reality: Many plaintiffs can't afford treatment, especially before settlement.

Work and Life Obligations

The reality: Plaintiffs have jobs, families, and responsibilities that compete with treatment.

Healthcare System Delays

The reality: The medical system creates its own gaps.

COVID-Era Gaps

Pandemic-related treatment gaps have their own considerations:

• Facility closures and reduced capacity
• Telehealth limitations for physical injuries
• Patient fear of exposure
• Elective procedure postponements

Documentation approach: Facility policies, public health orders, and patient safety concerns all support COVID gap explanations.

Identifying Gaps Before They Hurt You

The worst time to discover a treatment gap is when the adjuster points it out. Proactive identification gives you time to address it.

Gap detection checklist:

• Create treatment timeline from all records immediately
• Flag any period exceeding 14 days without care
• Cross-reference billing records with medical records
• Check for referrals that weren't followed up
• Verify imaging was completed after being ordered
• Confirm physical therapy attendance matches prescription

Red flags in medical records:

• "Patient no-showed" or "failed to appear" notes
• "Lost to follow-up" documentation
• Prescription refill gaps
• Discharge summaries without follow-up scheduled
• Referrals with no corresponding specialist visit

Mitigating Gaps in Your Demand

When gaps exist, address them directly. Silence looks like concealment.

Acknowledge and Explain

Don't hide gaps—adjusters will find them. Address them head-on:

"The plaintiff did not seek treatment between May 15th and June 30th, 2024. This gap resulted from her employer's denial of additional time off for medical appointments. As documented in Exhibit 14, her supervisor explicitly stated that further absences would result in termination. Medical records from her June 30th visit confirm that her symptoms persisted throughout this period and were consistent with her prior complaints."

Provide Supporting Documentation

Every gap explanation needs evidence:

Bridge the Gap Medically

The strongest gap mitigation is medical evidence that symptoms persisted:

• Post-gap records noting consistent complaints
• Provider statements that gap didn't affect prognosis
• Contemporaneous documentation (pain journals, texts to family)
• Return visit findings consistent with prior exams

Use Expert Support When Needed

For significant gaps in serious cases, consider:

• Medical expert opinion that gap didn't affect causation
• Vocational expert on work-related treatment barriers
• Mental health expert on treatment avoidance behaviors

Prevention: Stopping Gaps Before They Start

The best gap strategy is preventing them in the first place.

Client Education at Intake

Set expectations from day one:

Key messages for clients:

1. "Consistent treatment is as important as the treatment itself"
2. "Any gap over two weeks will be used against you"
3. "If you can't make an appointment, tell us immediately"
4. "Document everything—even why you missed an appointment"

Firm Process Changes

Build gap prevention into your workflow:

Early Intervention

When you spot a developing gap:

1. Contact the client immediately — Don't wait
2. Identify the barrier — Financial, logistical, or avoidance?
3. Problem-solve together — Find alternative providers, adjust schedules
4. Document the conversation — Create a record of the barrier
5. Follow up — Confirm treatment resumed

When Gaps Are Fatal to a Case

Some gaps cannot be rehabilitated:

Near-impossible to overcome:

• 6+ month gap with no explanation
• Gap followed by new injury to same body part
• Gap during acute phase (first 4-6 weeks)
• Multiple gaps throughout treatment
• Gap combined with contradictory surveillance

Still possible with strong facts:

• Single gap with documented barrier
• Gap in chronic phase with consistent prior treatment
• Gap with medical evidence of persistent symptoms
• Gap with contemporaneous documentation of ongoing complaints

Evaluate these cases carefully. The gap may warrant a reduced demand rather than fighting a losing battle.

Documentation Strategy for Gap Cases

When building a demand for a case with gaps, documentation is everything.

Your gap mitigation package should include:

1. Timeline visualization — Show the gap in context of overall treatment
2. Gap explanation — Clear statement of why treatment stopped
3. Supporting evidence — Documents proving the explanation
4. Continuity evidence — Proof symptoms persisted through gap
5. Medical support — Provider statements on causation if needed

Present the gap proactively:

"Anticipated Defense Arguments: The defense will likely point to the 45-day gap in treatment between May and July. As addressed in Section IV and supported by Exhibits 12-15, this gap resulted from [specific reason] and does not undermine causation for the following reasons..."

Taking this head-on shows confidence and prevents the adjuster from treating it as a "gotcha."

The Technology Advantage

Manual record review often misses treatment gaps—or finds them too late to address effectively.

What AI-powered analysis catches:

• Gaps between any two treatments, automatically flagged
• Missing follow-ups on referrals or imaging orders
• Prescription refill gaps suggesting treatment interruption
• Discharged without follow-up patterns
• Multiple small gaps that create a pattern

Catching gaps early—before they become problems—is the difference between a full-value settlement and a compromised one.

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