Claims Flashcards
Steps in the claims process
Report - Jurisdictional interpretation, establish reserve
Investigate- determination of coverage, duty to defend, reserve impact
Verify- court documentation, supporting documents, proof of loss, reserve impact
Evaluate- estimates, degree of negligence, reserve impact
Resolve- Pay or deny, mediation, litigation
RIVER
Claim department function
Fulfill promises, reserving, coverage consideration, recommendations for review at renewal
Jurisdictional interpretation
Noncompliance negates coverage in some jurisdictions
Elements of negligence
Duty owed- Offending party has a duty owed such as duty to safely operate an automobile
Duty breached- offending party must have breached duty owed
Damages - there must be damages such as property damage or bodily injury
Proximate cause- The breach of duty must be the proximate cause of the damage such as running a red light caused a collision that resulted in injuries
Reservation of rights letter
Unilateral. Letter sent by the insurance company explaining that although there is a question as to whether or not a claim is covered the insurance company will proceed with investigating and evaluating but reserves it’s right to deny later
Non-waiver agreement
Bilateral. A document signed by both the insurance company and the insured acknowledging there is a potential issue with coverage but the investigation is ongoing and the company reserves the right to deny later
Declaratory judgment
Binding adjudication establishes the rights and other legal relations of parties without providing an order of enforcement. Issued by a judge
Joint and several liability
Responsibility that is shared by two or more parties
Arbitration
Outside service provider who assembles a panel of claims experts to review a claim and make a decision which can be binding or non-binding
Mediation
Insured and claimant representative and insurance company meet to discuss the differences overseen by a third-party called the mediator, mediator assist in settling the dispute
Consent to settle
Consent from the insured to settle a claim
Hammer clause
Insurance company reserves the right to charge the insured for differences in cost of a claim if the insured delays the settlement process
Non-consent or no participation
Says the insurance company has the right to settle the claim not the insured
Buyout provision
Allows the insured who disagrees with the insurance company’s settlement to take the settlement from the insurance company and personally defend and settle the claim on their own
Hard fraud
Insured or claim and deliberately plans a loss that is covered by the insurance policy in order to receive payment
