Chapter 6 - Claims Flashcards
Define independent adjuster
One who adjusts losses on behalf of insurance companies but is not employed by any one insurance company
What are the three main roles of an adjuster?
Investigate, determine policy coverage, negotiate and settle claims
What three reasons might an insurer choose an independent adjuster?
- They are extremely busy
- Need a specialized type of knowledge
- Claim is far away and need someone who works in that location
How do independent adjusters differ from staff adjusters?
They must be licensed or certified
Define title washing
When the history of a salvaged vehicle has been hidden
What is the concern with large scale disasters?
They provide an opportunity for fraudsters to capitalize
What four conditions does a non-waiver agreement typically state that an insurer may do?
- Investigate the circumstances surrounding the claim
- Carry on negotiations
- Make a settlement or settlements
- Defend any action or actions which might be brought
What happens if the insured refuses to sign a non-waiver agreement?
A reservation of rights letter will be sent instead
Explain the purpose of the proof of loss form
Proof of loss is not an admission that a policy is in force or that coverage applies
It allows the insured to document the incident and any other significant details
Define interrogation
An investigative interview where the known facts are matched to a particular suspect for the purpose of obtaining a confession
What are the six steps in the investigative interview process?
1) Plan
2) Listen
3) Remain Calm
4) Ask one question at a time / make notes
5) Evaluate body language
6) Ask for an explanation
Interview process: Plan
Prepare, examine documentation/evidence, formulate questions, make checklists, do reserach
Interview process: Listen
Allow them to speak without interrupting
Interview process: Remain Calm
Do not get upset, do not use threatening language or gestures, if caught in a lie, can be used to test credibility
Interview process: Ask one question at a time
Do not overwhelm, ask questions and wait for answers, allow them to see your notes and make changes if necessary
Interview process: Evaluate body language
Do they seem uncomfortable, anxious or a bit too nonchalant
Interview process: Ask for an explanation
When unclear, always ask for clarification
What can a formal statement provide?
A map to direct an investigation; recollection when the incident is still fresh in their mind
What happens if the insured refuses to sign the statement?
It is still a useful/credible source of a discussion; allow them to read and record any objections
Will courts accept polygraph test results as evidence of lying?
No
There is debate on whether it is reliable; and it is subject to the tester’s interpretation
Can the insurer request a polygraph examination?
No, it must be entirely voluntary by the insured
What are the three stages of a polygraph test?
- Pre test interview
- Collection of data
- Analysis of the data
Define forensic expert
Someone connected to a court of law and can be hired by an insurer or an insured to appear in court as witnesses. These experts combine knowledge of legal cases of the principles of a profession. The expect can help to prove or contradict the cause of a claim
What five things should you consider when selecting an expert?
- Properly qualified
- Reputable firms/individuals
- Stable operations/individuals
- Those who conduct operations to avoid any liability/criticism to be brought to insurer
- Firms that value training/development
What are the types of experts?
Origin and cause specialists, appraisers, electrical/mechanical/chemical engineers, accident reconstruction specialists, surveillance specialists, photographers, doctors, forensic accountants, lawyers, computer technicians, forensic pathologists, employment consultants, forensic economists, forensic video analysis, forensic experimentation, any unique/specific knowledge
Who usually selects the expert?
Lead adjuster or examiner working on the claim
What could you review to determine if useful analysis has occurred?
- Was proper testing carried out?
- How soon after the loss was the scene inspected?
- What evidence might be affected by not being in continuous custody?
- What effort was made to determine whether there were any changes to the scene since the loss?
- Was evidence properly handled?
What was the relevance of Wise v. Dominion of Canada General Insurance Co. (2009)?
Insured had auto accident, requested 24 hour care; facebook photos sowed they had been involved in physical activity
What was the relevance of Frangione v. Vandongen (2010)?
The definition of privacy
The plaintiff argued that there was an invasion of privacy by using Facebook; however the plaintiff had 200 “friends” and it was not private info, so evidence was admissable
What six things should an adjuster know if they are required to testify in court?
1) Make and keep detailed notes / consult others if needed
2) Review notes and important points prior to court date
3) Make a conscious effort to speak slowly and clearly
4) Listen carefully to each question, take your time
5) If you are not sure what is being asked, ask for it again or for it to be reworded
6) Answer what is being asked and be concise
Why is it important to educate the client about the claims process?
So they understand insurance fraud, what to expect and what to watch for from other parties who may be committing fraud
What must be done to review the report of an expert?
- Must be objectively examined
- Expert opinion will be evaluated
- Must be neutral
- If not neutral, judges will be skeptical
