Chapter 6 - Claims

Question 1

Define independent adjuster

Answer 1

One who adjusts losses on behalf of insurance companies but is not employed by any one insurance company

Question 2

What are the three main roles of an adjuster?

Answer 2

Investigate, determine policy coverage, negotiate and settle claims

Question 3

What three reasons might an insurer choose an independent adjuster?

Answer 3

• They are extremely busy
• Need a specialized type of knowledge
• Claim is far away and need someone who works in that location

Question 4

How do independent adjusters differ from staff adjusters?

Answer 4

They must be licensed or certified

Question 5

Define title washing

Answer 5

When the history of a salvaged vehicle has been hidden

Question 6

What is the concern with large scale disasters?

Answer 6

They provide an opportunity for fraudsters to capitalize

Question 7

What four conditions does a non-waiver agreement typically state that an insurer may do?

Answer 7

• Investigate the circumstances surrounding the claim
• Carry on negotiations
• Make a settlement or settlements
• Defend any action or actions which might be brought

Question 8

What happens if the insured refuses to sign a non-waiver agreement?

Answer 8

A reservation of rights letter will be sent instead

Question 9

Explain the purpose of the proof of loss form

Answer 9

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

Question 10

Define interrogation

Answer 10

An investigative interview where the known facts are matched to a particular suspect for the purpose of obtaining a confession

Question 11

What are the six steps in the investigative interview process?

Answer 11

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

Question 12

Interview process: Plan

Answer 12

Prepare, examine documentation/evidence, formulate questions, make checklists, do reserach

Question 13

Interview process: Listen

Answer 13

Allow them to speak without interrupting

Question 14

Interview process: Remain Calm

Answer 14

Do not get upset, do not use threatening language or gestures, if caught in a lie, can be used to test credibility

Question 15

Interview process: Ask one question at a time

Answer 15

Do not overwhelm, ask questions and wait for answers, allow them to see your notes and make changes if necessary

Question 16

Interview process: Evaluate body language

Answer 16

Do they seem uncomfortable, anxious or a bit too nonchalant

Question 17

Interview process: Ask for an explanation

Answer 17

When unclear, always ask for clarification

Question 18

What can a formal statement provide?

Answer 18

A map to direct an investigation; recollection when the incident is still fresh in their mind

Question 19

What happens if the insured refuses to sign the statement?

Answer 19

It is still a useful/credible source of a discussion; allow them to read and record any objections

Question 20

Will courts accept polygraph test results as evidence of lying?

Answer 20

No

There is debate on whether it is reliable; and it is subject to the tester’s interpretation

Question 21

Can the insurer request a polygraph examination?

Answer 21

No, it must be entirely voluntary by the insured

Question 22

What are the three stages of a polygraph test?

Answer 22

• Pre test interview
• Collection of data
• Analysis of the data

Question 23

Define forensic expert

Answer 23

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

Question 24

What five things should you consider when selecting an expert?

Answer 24

• 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

Question 25

What are the types of experts?

Answer 25

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

Question 26

Who usually selects the expert?

Answer 26

Lead adjuster or examiner working on the claim

Question 27

What could you review to determine if useful analysis has occurred?

Answer 27

• 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?

Question 28

What was the relevance of Wise v. Dominion of Canada General Insurance Co. (2009)?

Answer 28

Insured had auto accident, requested 24 hour care; facebook photos sowed they had been involved in physical activity

Question 29

What was the relevance of Frangione v. Vandongen (2010)?

Answer 29

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

Question 30

What six things should an adjuster know if they are required to testify in court?

Answer 30

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

Question 31

Why is it important to educate the client about the claims process?

Answer 31

So they understand insurance fraud, what to expect and what to watch for from other parties who may be committing fraud

Question 32

What must be done to review the report of an expert?

Answer 32

• Must be objectively examined
• Expert opinion will be evaluated
• Must be neutral
• If not neutral, judges will be skeptical