2/C - Adjusting the Claim Flashcards
The 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 communication
- 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 & phone number
- Respond to the claimant’s communications promptly
- Answer any questions
Prepare Paperwork
- 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:
a. help insurer begin its investigation
b. often due within 60 days
- Promptly follow up with additional paperwork, if required
The Claim File
- Preparing Paperwork: The Claim File
- Organized source of documentation for all claim details
- Copies of all communications
- Evidence from investigation, such as:
a. photos/sketches of property
b. copies of medical bills
c. copies of all claim forms
d. witness statements
- Claim file must reconstruct the loss and how it was handled
Determine Insurer’s Liability
- Determine Insurer’s Liability in the Claim
- Was the policy active at the time of loss?
- Does the claimant have insurable interest?
a. do any other parties have insurable interest (mortgage company, etc.)?
- Does the policy cover the type of damage or injury being claimed?
a. does the policy cover the proximate cause of the loss?
- 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?
a. if covered, move on to the next step
b. if NOT covered, deny the claim with a full explanation
Reservation of Rights
Tells claimant the insurer will stat the claim, but might deny it
Used when:
- There is a coverage dispute
- The claimant took too long to report claim
Investigate a Property Claim
- Inspect damages
- Take photos
- Interview claimant and witnesses
- Review police report
- Consult with professionals
Liability Claims
Investigation: Liability Claims
Bodily Injury:
- 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 condition contribute to injury?
Other Liability Claims:
- Is policyholder liable?
- Is anyone else partially responsible?
- Is a lawsuit imminent?
- How much would defending a lawsuit cost?
- What is the probability of winning?
Critical Evidence
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 point of impact
Official Reports
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 from previous crimes
- Birth and marriage certificates
- Coast guard reports (boating incidents)
- Civil Aircraft Board (C.A.B.) reports (aircraft)
Additional reports helpful for auto claims:
- State reports filed by the people involved in the accident
- Motor vehicle inspections
- Traffic court proceedings
- Hack bureau reports if the accident involved a taxi
- Reports from the Interstate Commerce Commission (ICC) for trucking accidents
Other Evidence
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
Written Statements
Investigation: Written Statements
- Introduction:
a. identify interviewer and interviewee
b. date, time, and place of interview
- Body:
a. where, when, how the loss occurred
b. description of injuries
c. make and model of cars involved
d. where the driver started out, was headed, and why
e. what happened after the accident (conversations,
police, ambulance, hospitals, etc.)
- Conclusion:
a. interviewee verifies in own handwriting that the
statement is true
b. signature below conclusion on right of page
c. witness signs on left
Recorded Statements
Investigation: Recorded Statements
- Introduction:
a. state names and locations of everyone on recording
b. age and address of interviewee - Body:
a. same goal as written interview
b. recording must be continuous: explain any interruptions
c. stay objective: no leading or argumentative questions
d. avoid excessive sympathy
e. don’t discuss insurance or settlements - Conclusion:
a. interviewee has a chance to add or change any details
b. interviewee must verify that he understood all questions and answered honestly
c. interviewer states again that conversation was recorded
