Ch 7 Flashcards
How does the claims department help the insurer comply with the contractual promise?
By providing fair, prompt, and equitable service to the insurer, either (1) directly, when the loss involves a first-party claim made by the insured against the insurer, or (2) indirectly, by handling a third-party claim made by someone against the insured to whom the insured might be liable.
What are the two primary goals of the claim function?
1) Complying with the contractual promise
2) Supporting the insured’s financial goals
How does the claims department support the insurer’s financial goals.
By managing all claim function expenses, setting appropriate spending policies, using appropriately priced providers and services, and ensuring fair claim settlement.
Success in achieving its financial goal is reflected in its reputation got providing the service promised.
How does marketing use information from the claims department?
Marketing needs information about customer satisfaction and timeliness of settlements.
The claim handling process can also be a source of new coverage ideas and product innovations for niche markets.
How does information from the claims department assist producers?
Helps producers explain premium changes as claims usually affect renewal premium.
Claims also informs producers of court rulings that affect the insured’s loss exposures or pricing. (Ex. Interpretation of policy exclusions or application of limits)
How does the claims department assist underwriting?
Proper, consistent, and efficient claim handling enables underwriters to evaluate, select, and appropriately price loss exposures based on consistent loss costs.
When inspecting property, claims may point out information that underwriting is unaware of and underwriting can cancel coverage, request corrective measures, or adjust premium.
A number of similar claims could alert underwriting management to a problem with a particular class or type of insured or an adverse court ruling. This could be due to new technologies add by an insured (ex. Dangerous method of roofing)
How does the claims department assist actuarial?
Provide information on incurred losses.
Provide information on loss adjusting expenses and recovers me amounts associated with claims (salvage, reinsurance, subrogation, deductibles to be repaid by the insured)
When claim payments are recorded accurately and realistic reserves are set in the insurer’s claim processing system, the raw data that actuaries use to develop rates will be accurate, and the rates will reflect the insurer’s loss experience.
How does the claims department claims interact with lawyers?
Claimants hire attorneys. The insurer may also need an attorney. Claims will assist the insured’s lawyer as needed by sharing claim details and assembling information that supports the insurers position.
How does the claims department interact with the public?
The claims department largely determines the insured’s public image since they are the primary contact.
People involved in losses are emotional and the claims rep is their first contact. The claims rep must be empathetic.
Technological improvements have helped insured improve the quality and speed of claim service.
How does the claims department work with State Regulators?
Some claim representatives are subject to licensing. Regulators investigate complaints and perform market conduct investigation. Enforcement is handled through Unfair Claims Settlement Practices act.
Claim reps must respond to inquiries from the insurance department within a certain time frame or be subject to fines or loss of license.
An organization that provides administrative services associated with risk financing and insurance.
Third-party administrator.
Employees of an insurer who handle most claims. These include inside claim reps and field claim reps (outside claim reps).
Staff Claim Representatives
An independent claim representative who handles claims for insurers for a fee.
Independent Adjuster
Under which situations does an insurer use an independent adjuster?
Some use independent adjusters for all field work. Some use independents for overload, catastrophes, or special claims and some use independents when it is not feasible to set up claim offices in certain areas.
An organization or person hired by an insured to represent the insured in a claim in exchange for a fee.
Public adjuster
Incurred Losses
The losses that have occurred during a specific period no matter when claims resulting from the losses are aid.
An insurer’s incurred losses (including loss adjustment expenses) for a specific period divided by its earned premiums for the same period
Loss Ratio
The portion of written premiums that corresponds to coverage that has already been provided.
Earned Premium
An insurer’s incurred underwriting expense for a specific period divided by its written premiums for the same period
Expense Ratio
What is the formula for the combined ratio?
Loss Ratio + Expense Ratio
What are three of the more frequently used measures to gauge claims department performance?
best practices, claim audits, and customer satisfaction
A system of identified internal practices that produce superior performance. They are created by either studying the insurer’s own performance or the performance of similar successful insurers and they are often based on legal requirements.
Best practices.
List the activities that provide a framework for handling claims.
- Acknowledging and assigning the claim.
- Identifying the policy and setting reserves
- Contacting the insured or the insured’s representative
- Investigating the claim
- Documenting the claim
- Determining the cause of loss, liability, and the loss amount
- Concluding the claim
What does a claim rep send to the insured when it becomes apparent that coverage may not be available for a loss?
A reservation of rights letter or nonwaiver agreement.
What are the tasks completed in acknowledging and assigning the claim?
- Acknowledge claim has been received
- Assign the claim
- Assign to a CR that has the skills to handle claim
- Contact insured or third party
Nonwaiver Agreement
A signed agreement indicating that during the course of the investigation, neither the insurer nor the insured waives rights under the policy.
Reservation of Rights Letter
An insurer’s letter that specifies coverage issues and informs the insured that the insured that the insurer is handling a claim with the understanding that the insurer may deny coverage should the facts warrant it.
What are the two methods of loss reserving that rely on the claim rep’s judgment?
individual case and roundtable mehods.
A method of setting reserves based on the claim’s circumstances and the claim rep’s experience in handling similar claims? The reserves set by this method can vary widely by claim rep.
individual case method
This method of setting reserves by using the consensus of two or more claim personnel who have independently evaluated the claim file is time consuming so it is not usually used for initial reserves; it is suitable for serious or prolonged claims.
roundtable method
This method of reserving establishes a predetermined dollar amount of reserve for each claim as it is reported. It is usually used as the initial reserve and is modified within a specified number of days.
average value method
This method of reserving sets reserves using a mathematical formula.It is based on an assumption that ratios exist between certain costs such as the medical cost and indemnity (or wage loss) in a workers comp claim. It is frequently used to set the additional living expense reserve under a homeowners policy if a home is destroyed by fire.
Formula method
A method of setting reserves with a software application that estimates losses and loss adjustment expenses.
expert system method.
A loss reserving method that establishes aggregate reserves for all claims for a type of insurance. It is used to suggest standard reserves for similar types of claims or for a class of loss exposures. This method is suitable for claims that are reported long after the expiration date of a policy, for example medical malpractice.
loss ratio method.
What does the IBNR reserve usually also include an allowance for?
Reported losses for which the case reserves are judged to be inadequate and a reserve for claims that have been closed and then reopened.
When setting a reserve using the individual case method, which factors are examined?
1) Claimant profile (age, sex, occupation, education, dependents)
2) nature and extent of injury (permanency, pain &suffering?, lifestyle disruption)
3) special damages (quantified)
4) claimant representation
5) liability factors (negligence, comp neg?, legal limit to recovery (cap on certain damages)
6) misc. factors (economic conditions in geographic area), was insured’s conduct outrageous, etoh/drug use?, insured’s credibility as witness, claimant credibility as witness)
What happens if claims are not adequately and accurately reserved?
The ratemaking process could
be distorted and the insured’s capacity could be reduced. If this continues, solvency could be threatened.
How are reserve errors caused?
Initial reserve may be inaccurate because they are determined based on limited information. Failure to review reserves could cause an error.
Poor planning, lack of expertise in estimating claim severity, or unwillingness to re-evaluate the facts. This can result in stairstepping.
Not anticipating inflation and ultimate cost of a claim that takes years to settle.
Overconfidence of ability to conclude a claim for a lesser amount.
Keying error.
What is stairstepping and which claims does it affect most?
Incremental increases in claim reserves by the claim rep without any significant change in the facts of the claim. This is a concern for claims that could remain open for many years. If new information comes to light and the reserve is increased, it is not stairstepping.
What purposes does initial contact with the insured serve?
Reassure the insured that the claim will be investigated.
Gives rep a chance to explain the process.