Chapter 4 Adjusters

Question 1

Adjuster Practices, Responsibilities, and Duties

Answer 1

As an insurance professional, the adjuster has many duties and responsibilities to adhere to. These duties may or may not be spelled out by the insurer, but the adjuster must understand and follow their duties in order to be considered a true professional at their craft. Claim adjusting is a customer service profession. The adjuster should always be focused on providing exemplary customer service. The following info provides effective customer focused behavioral traits of successful adjusters.

As an adjuster, you are expected to make initial contact within 24 hours of receiving a loss notice. You must also set proper claim expectations with the PH and follow up with them to make sure they are informed throughout the claim process.

The adjuster needs to ascertain what the PH believes is the cause of the loss and the extent of damage. By determining the cause of loss and extent of damage, the adjuster will be alerted as to what the severity of the claim might be.

The adjuster must set appointments at reasonable times to meet both the needs of the adjuster and the PH. The adjuster must always show respect to the P and other parties associated with the claim. Treat the PH with respect and remember they are a person, not a claim number.

Proper claim handling is essential for the adjuster to achieve positive results. The adjuster should keep a detailed log of all claim activity. The claim activity log (diary) must be clear, concise, factual, and always up to date.

Whenever a claim is denied, either fully denied or partially denied, it must be followed up in writing explaining the lack of coverage.

Adjusters are responsible to the insurer to:

• be loyal to the insurer’s interest;
• avoid engaging in any business activity that competes or interferes with the insurer’s business;
• obey all legal instructions provided by the insurer;
• perform all duties with the degree of care and skill that a reasonably prudent person would exercise in the same circumstances; and
• keep the insurer informed of all the facts related to the claims that they are handling.

As an insurance professional, the adjuster must have procedures set in place to ensure that the adjustment of the claim is completed without overlooking essential information and details concerning the loss.

There are several approaches that can be made to adjusting a loss, yet those approaches vary depending on the situation and the type of loss.

Question 2

General checklist of procedures that are typically followed by property adjusters:

Answer 2

1. Verify policy info;
2. Contact & meet with the insured;
3. Inspect the property & damages thoroughly;
4. Examine any pertinent documents and reports, such as police and fire reports;
5. Review prior losses;
6. Investigate if there is other insurance policies that may cover the loss;
7. Analyze coverage and either settle or deny the claim;
8. Estimate the amount of damage, if coverage is applicable;
9. Document subrogation potential;
10. Document any salvageable materials;
11. If there is coverage, indemnify the insured for their loss in a timely fashion; and
12. If the claim is denied, it must be denied in writing.

A crucial element to the adjustment process is the claim investigation. The adjuster should promptly begin interaction with the PH and determine the extent of damages. Once the adjuster has a complete understanding of the extent of damage, he or she can provide the PH with advice on how to mitigate the damages.

When communicating with the PH, the adjuster should always display professionalism, express empathy, and have a respectful tone. Always remember as a claim professional you must be a guiding force through the claim process without being overly forceful. The PH is going through a traumatic event and is looking for the adjuster to be knowledgeable, respectful, and compassionate.

As an adjuster, you must be sensitive to the situation. Allow the PH to tell their story and then show concern and thoughtfulness.

It is the adjuster’s obligation to investigate and verify the cause of loss. In some instances, the cause of loss will be clear and coverage can be determined readily. In other cases, the cause of loss may require an extensive investigation to determine what peril occurred, and if the loss will be covered.

The purpose of the investigation should not be directed toward supporting an assumption, but rather toward determining all the facts in support of a rational conclusion.

Question 3

The elements of Good Service

Answer 3

• Proactive approach to claim handling.
• Timely follow up;
• Complete tasks as promised;
• Effective communication

Question 4

Handling difficult policy holders

Answer 4

When handling a difficult PH, you should always remain calm and display a high level of professionalism. The following are positive approaches:

• Negotiate, always try and find a middle ground;
• Keep your cool and don’t become argumentative;
• Be a good listener;
• Be knowledgeable;
• Be an effective communicator; and
• Always be honest.

Question 5

Privacy

Answer 5

Protecting a PH’s privacy is an ethical responsibility and an area of increasing liability. Adjusters have access to highly personal information. Use extreme care to make sure you are keeping their information private and secure. It may seem obvious and oversimplified, but the info on the adjuster’s file is extremely confidential and all efforts to make it secure should be practiced. Remember, the adjuster files are accessible by an insurance company and/or a plaintiff’s attorney.

Question 6

Ways to minimize privacy conflicts

Answer 6

The best approach to guard client info is to establish guidelines for handling files and communications. It goes without saying that since others have access to your files it would be wise to never make a written derogatory comment or reveal some personal information about a PH.

Question 7

Ethical considerations

Answer 7

As an adjuster, it is very important that you handle all matters using high ethical standards. The following is a list of professional standards that all adjusters must comply with in order to have a successful adjusting career.

1. An adjuster shall not directly or indirectly refer or steer any claimant needing repairs or other services in connection with a loss to any person with whom the adjuster has an undisclosed financial interest, or who will or is reasonably anticipated to provide the adjuster any direct or indirect compensation for the referral or for any resulting business;
2. An adjuster shall treat all claimants equally and not provide favored treatment to any claimant;
3. An adjuster shall adjust all claims in accordance with terms and conditions of the insurance contract;
4. An adjuster shall not approach investigations in a manner prejudicial to the PH;
5. An adjuster shall handle every adjustment and settlement with honesty and integrity, and allow a fair adjustment or settlement to all parties without any renumeration to himself except that to which he is legally entitled;
6. An adjuster shall make truthful and unbiased reports of the facts after completing a complete and thorough investigation;
7. An adjuster shall exercise extraordinary care when dealing with elderly or disabled clients to assure that they are not disadvantaged in their claims transactions by failing memory or impaired cognitive process;
8. An adjuster shall act with due diligence in achieving a proper disposition of the claim;
9. An adjuster shall not negotiate or effect settlement directly or indirectly with any third-party claimant represented by an attorney, if the adjuster has knowledge of such representation, except with the consent of the attorney;
10. An adjuster shall not advise a claimant to refrain from seeking legal advice;
11. An adjuster shall not attempt to negotiate or obtain any statement from claimant or witness at a time that the claimant or witness is, or would reasonably be expected to be in shock or serious mental or emotional distress as a result of physical, mental, or emotional trauma associated with a loss;
12. An adjuster shall not knowingly fail to advise a claimant of their rights in accordance with the terms and conditions of the contract and of the applicable laws of the state;
13. An adjuster shall not engage in the unlicensed practice of law as prescribed by the state bar; and
14. Adjusters should always work in good faith to obtain a fair and equitable claim settlement.