09. Adjusting the Claim Flashcards
Claim
A formal request to settle the damage
- claimant must prove the loss and submit the total to insurer
- insurer sends an adjuster, who must decide whether claimant has adequately proven the loss
The Steps of the Claims Process
- Acknowledge the claim
- Establish lines of communism
- Prepare necessary paperwork
- Determine insurer’s liability in the claim
- Investigate the losses
- Determine the time and cost of repairs
- Apply all policy coverages and provisions
- Negotiate a settlement
- Prepare final reports
Acknowledge the Claim
- respond within required amount of time
- contact via letter or phone call
- keep track of the date of first contact
- adjuster: liaison between claimant and insurer
Open Lines of Communication
- make sure there is a way to communicate with claimant
- provide current business address and phone number
- respond to the claimant’s communications promptly
- answer any questions
Prepare all Necessary Paperwork
- determine the type of claim it is
- prepare the necessary paperwork to process the claim
- make sure the claimant receives and understands how to complete the required paperwork
- proof of loss forms:
- help insurer begin its investigation
- often due within 60 days
- promptly follow up with additional paperwork, if required
Preparing Paperwork ( the claim file )
- organized source of documentation for all claim details
- copies of all communications
- evidence from investigation, such as:
- photos/sketches of property
- copies of medical bills
- copies of all claim forms
- witness statements
- claim file must reconstruct the loss and how it was handled
Determine Insurer’s Liability in the Claim ( 1 - 3 )
1.) was the policy active at the time of loss?
- ) does the claimant have insurable interest?
- do any other parties have insurable interest ( mortgage company etc.)
- ) does the policy cover the type of damage or injury being claimed
- does the policy cover the proximate cause of the loss
Determine Insurer’s Liability in the Claim ( 4 - 6 )
- ) is there a history of similar claims? If so have they reduced the policy limit available for this loss?
- ) will any other policies cover this loss?
- ) has the insured met all requirements of the contract
- ** if covered move on the next step ( start of investigation )
- ** if NOT covered deny the claim with a full explanation ( no fucking shit )
Investigation: Property Claims
- inspect damages
- take photos
- interview claimant and witnesses
- review police report
- consult with professionals
*** witness in recorded interview must be given a chance to correct anything that is incorrect in his statement
Investigation: Liability Claims
- type of injury
- copies of all medical bills and receipts
- documentation of lost wages
- how severe is the disability, impairment, or disfigurement
- are general damages covered
- did any pre-existing conditions contribute to injury?
( other questions: is policyholder liable, any one else partially responsible, any lawsuits imminent, how much would defending a lawsuit cost, what’s the probability of winning )
Investigation: Critical Evidence
- examine scene of loss or damage
- photograph damage
- sketch the property
- take statements from claimant and the at-fault party ( if applicable )
- inspect and photograph the damaged cars
- document skid marks to help determine points of impact
Investigation: Official Reports
- police reports
- fire department reports
- death certificates
- autopsy reports
- coroner’s inquests
- medical reports
- weather reports from the time of the loss
- school records
- court records
- court records from the previous crimes
- birth and marriage certificates
- coast guard reports (boating incidents)
- civil aircraft board (C.A.B) reports (aircraft )
- auto accident reports
- traffic court proceedings
- vehicle inspections
Investigation: Other Kinds of Evidence
Documentary/Visual Evidence
- deeds/leases
- diagrams
- sketches
- photos
- x-rays
- contracts for construction or repair
- employer records for wage loss claims
Industry Experts - doctors and medical examiners - car inspectors - engineers in the field ( mechanical, structural, electrical, etc.) - actuaries - handwriting experts
Investigation: Written Statements
witness statements can be useful for:
- revealing new information
- painting claim picture from different viewpoints
- disputing account given be claimant or other witness
- impeaching witness credibility if he changes his story in court
( 3 parts of statement: intro, body, conclusion )
6.) Evaluation Step 1: Determine the Cost of Repairs
- cost to repair or replace damaged property
- additional expenses caused by the loss
- any applicable medical bills
- lost wages
- time-frame of repairs
