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Basic Claims Training > November 5-9, 2018 > Flashcards

November 5-9, 2018 Flashcards

1
Q

What is Contributory Negligence and how does it apply to a claim?

A

1% bars recovery

If you are 1% or more responsible you cannot seek recovery of your damages from the other party

e.g. Insd 95%; clmnt 5% = no collection
Insd 100%, clmnt 0% = collects all
Insd 0%, clmnt 100% = clmnt collects all

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2
Q

What is Modified Comparative 51% and how does it apply to a claim?

A

51% bars recovery.

If you are 51% or more responsible you cannot collect the portion you are not negligent for.

e.g. Insd 60%; clmnt 40% = insd cannot collect
Insd 40%; clmnt 60% = insd can collect 60%

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3
Q

What is Modified Comparative 50% and how does it apply to a claim?

A

50% bars recovery.

If you are 50% or more responsible you cannot collect the portion you are not negligent for.

e.g. Insd 60%; clmnt 40% = insd cannot collect
Insd 40%; clmnt 60% = insd can collect 60%
Insd 50%; clmnt 50% = neither party can collect

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4
Q

What is Pure Comparative negligence and how does it apply to a claim?

A

The % you are responsible is NOT collectible from the other party.

E.g. Insd 60%; clmnt 40% = insd collects 40%
Insd 30%; clmnt 70% = insd collects 70%
Insd 0%; clmnt 100% = insd collects all

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5
Q

How does “pro-rata” apply to a claim and how is it calculated?

A

Limits calculations with multiple claimants.

PD limit / total all clmnts dmgs = share % (keep all decimals)

Share % x each clmnts dmgs = that parties share of damages

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6
Q

What is Slight vs. Gross negligence? How does it apply to a claim?

A

Slight: mere failure to exercise reasonable care

Gross: Conscious & voluntary disregard of the need to use “reasonable care” likely to cause injury/damage.

Gross = proximate cause
Slight = minor cause
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7
Q

What is a contract of adhesion?

A

Sold “as-is”.
Take it or leave it
Terms & conditions set by one party

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8
Q

What are the parts of a policy?

A 
Declaration page
Definitions
Insuring agreement
Conditions
Endorsements & exclusions
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9
Q

What does an endorsement do?

A

Changes the policy

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10
Q

What is our contract with our insured?

A

We promise to “defend & indemnify”. i.e. the insuring agreement.

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11
Q

What is first-party bad faith?

A

When we (the insurance company) fail to defend and indemnify our insd.

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12
Q

What is a third-party bad faith?

A

When we (the insurance company) fail to settle within policy limits

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13
Q

What coverage is both a contractual and liability coverage?

A

UM: Uninsured motorist
UIM: Underinsured motorist

Because it is both contractual (1st party) but treats the insd as if they were the clmnt (3rd party) but applying negligence.

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14
Q

What information is found on the Declaration page of a policy?

A
  • Insds name and contact information
  • Policy limits and coverage
  • Endorsements
  • Vehicles
  • Drivers/excluded drivers
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15
Q

What four (4) things make up the parts of a contract?

A
  1. Consideration (i.e. premium)
  2. Agreement (signed)
  3. Competent parties (of age, etc)
  4. Legal (complies with State law)
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16
Q

What are 1st party coverages?

A 
Collision
Comprehensive
Rental
Towing
MedPay
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17
Q

What are 3rd party coverages?

A

Property damage

Bodily injury

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18
Q

What are types of coverage issues?

A
  • Unlisted vehicle
  • Unlisted driver
  • Cancelled policy
  • Unlisted household member
  • Felories
  • NMOP w/SR-22
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19
Q

Who or what is a tort-feasor?

A

The wrong-doer.

Can be the party or their insurance company.

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20
Q

What three (3) things do we investigate as part of a claim?

A
  1. Coverage
  2. Liability
  3. Damages
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21
Q

What are two (2) types of extra-contractual exposures?

A

Punitive damages: Punishes

Exemplary damages: Make an example

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22
Q

What does SR-22 / FR-44 do to a policy?

A

Is a financial responsibility agreement by insurance company to the insd. Can be by:

  • Vehicle: anyone driving is covered
  • Person: just that person is covered

If we pay under SR-22/FR-44 when we otherwise wouldn’t, we can recover the payment from the insd.

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23
Q

What does ROR mean?

A

“Reservation of Rights”

Reserves our right to deny a claim by invoking a provision of a policy.

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24
Q

What are the requirements when sending an ROR?

A
  1. Send certified
  2. Address to insd
  3. Reference claim, facts, and allegations
  4. Reference applicable policy language
  5. Address statutory wording requirements.
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25
Q

When can you cancel an ROR notice? How do you cancel it?

A

When the coverage issue has been resolved by either payment or denial.

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26
Q

What does CDN stand for?

A

“Coverage Dispute Notice”.

It is when the insd, agent, or both, disputes the coverage we tell them they have.

e.g. they thought they had rental

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27
Q

What is a bailment?

A

“Permissive Use”.

When 1 party uses someone else’s property with permission.

BAILEE: person who uses/borrows
BAILOR: person who loans/owns

NOT a civil tort

28
Q

How do you handle an excess exposure?

A
  1. Call the insd and send cert. letter
  2. Call the clmnts/their insurance and advise of excess issue and first offer.
  3. Call the insd, advise of issue and ask if he can contribute funds
  4. Call clmnts/their insurance and offer new offer with insds funds (if applicable). Must disclose source of funds.
  5. If all can’t agree, file a Petition with the Court to turn over the money
29
Q

What is civil law?

A

An action brought by the wrong party (tort-feasor)

aka Common law/Case law or State law/Written law (can also be civil)

Judgment: Majority must agree
Punishment: monetary awards

30
Q

What is criminal law?

A

An action brought by the government (e.g. State, County, Police, etc).

aka State law/Written law (can also be civil)

Judgment: All parties must agree
Punishment: jail time, restitution. community service

31
Q

What is Sentry negotiation philosophy?

A

Make the 1st offer. Waiting can increase the exposure.,

32
Q

What are the four (4) parts of a negligence evaluation?

A
  1. Duty owed
  2. Duty breaches
  3. Proximate cause
  4. Damages
33
Q

What does EOS stand for and to what coverage does it apply?

A

“Early Offer Settlement”

Applies to non-severe bodily injury claims.
We settle for the current (todays) value.

includes “specials” (invoices) + inconvenience

34
Q

What does Affirmative Defense mean?

A

Are facts, other than those alleged by the Plaintiff, which, if proven, can mitigate or defend legal consequences.

35
Q

What are types of Affirmative Defense?

A 
Last clear chance. 
Unavoidable accidents.
Wrong jurisdiction
Comparative negligence
Limited or no harm
Intervening cause
36
Q

What are no-fault laws?

A

Unavoidable accidents

Includes:

  1. Act of God (e.g. flood, hurricane)
  2. Sudden emergency doctrine (e.g. stabbing)
  3. Illness without forewarning (e.g. seizures). Must have no prior suspicion of illness.
37
Q

What is an Intentional Tort?

A

An intentional act with premeditation. With intent, or at the direction of. Reasonably certain to cause harm or damage.

e.g. Vandalism, ramming accidents, etc.

38
Q

What does ITP mean?

A

Innocent third-party

A party who shares no negligence. e.g. passengers, unoccupied vehicles.

39
Q

What is joint & several liability?

A

Involves more than one tort-feasor.

ITP (innocent third-party) has right to choose to pursue recovery from either tort-feasor & other tort-feasor may pursue contribution.

40
Q

What is contribution and how does it apply?

A

What one tort-feasor pays more than their share to ITP and seeks reimbursement of the portion they are not responsible for.

e.g. Shared liability

41
Q

What is latent defect?

A

Transfer of legal liability as a result of faulty workmanship or product failure from insd to responsible vendor.

e.g. oil change, tire rotation, manufacturers recall.

42
Q

What is control of animals? what are the three (3) kinds?

A

When an animal is struck by a vehicle it is the law that applies to whether or not the vehicle owner is responsible for paying the value of the animal, or whether the animal owner is responsible for the vehicle.

Open range:
Closed range:
Leash laws:

43
Q

What is Strict liability? Where does it apply?

A

Products: manufacturers & parties in chain-of-distribution. e.g. warning stickers?

Absolute: dangerous activities, wild animals, explosives

44
Q

What is a Statute of Limitations?

A

The length of time someone has to pursue a claim.

Differs from State to State.

45
Q

What is vicarious liability?

A

Liability of the tort-feasor is transferred to another party who is not actively involved in a loss.

e.g. Tender age (under 7)/minor
Employer/employee

46
Q

When does a Statute of Limitation start and end for a minor?

A

Starts: when the minor reaches the age of majority for their State.

Ends: When the time limit for the coverage/liability length for that State ends.

47
Q

Who or what is the NICB?

A

National Investigative Crime Bureau.

The agency that keeps track of insurance fraud and suspected fraud.

48
Q

Difference between commission or ommission

A

Commision is the act of doing something.

Ommision is the act of failing to do something.

49
Q

What is Adverse Selection and how does it apply?

A

Is when an insured wanted us (the insurance company) to cover a recently acquired vehicle that has been in an accident but has not been added to the policy (that is within the 3 or 14 day acquiring period and would otherwise be covered) when not all vehicles owned by the insured are covered by us.

We will not cover the insured in the above case under Adverse Selection.

50
Q

What is “Last Clear Chance” and how does it apply?

A

Includes:

  • Foreseeable hazard
  • Opportunity to avoid
  • Failure to take opportunity
51
Q

What are the three (3) kinds of care owed?

A

Relates to bailment.

  1. Ordinary and reasonable: mutual benefit to both parties
  2. Slight care: sole benefit to bailor
  3. High care: sole benefit to bailee
52
Q

What are special and general damages? What do they apply to?

A

Special: tangible. e.g. invoices, bills, heating pads, crutches, etc

General: pain and suffering, scarring, etc.

For EOS we pay specials + inconvenience only.

53
Q

What is “subrogation” and how does it apply?

A

1st party: Process of collecting reimbursement for damages paid to our insured when we are not responsible (negligent free)

3rd party: When someone is seeking reimbursement from us for payments made that they are not responsible for.

54
Q

What is ACV?

A

Actual cash value

Replacement cost - depreciation.

55
Q

What is Diminished Value?

A

The difference between a vehicles current value of a vehicle (after repair completion) and the value of the vehicle prior to the loss.

**only applies to clmnt except in GA

56
Q

What is Sentry reserving policy?

A

Mid-point.

The middle range of what we are willing to pay, today.

57
Q

What is an EDR?

A

Event Data Recorder.

The black box found in a vehicle.

58
Q

What is “salvage value”?

A

The amount a vehicle can be sold for “as is”.

The salvage value is taken into consideration when a vehicle is a total loss and the owner chooses to retain, or not retain, their vehicle. If the owner chooses to retain their vehicle, their payment would only be actual cash value (minus UPD). If they choose to turn over their vehicle they would also get salvage value.

59
Q

What is an “Appearance Allowance”?

A

A payment made to a party for a minor imperfection that without payment of same, may result in the vehicle being determined to be a total loss. e.g. small scratch, minor dent

60
Q

What does ISO mean?

A

Insurance Services Organization

Not to be confused with “ISO claim search”

61
Q

What are typical ISO searches?

A
  • Name
  • Address
  • VIN
  • Phone number
62
Q

What are three (3) questions used to establish whether lookout was taken?

A

Did you see the other car?
Were there any obstructions?
Were you distracted by anything?

63
Q

How do excess and primary relate to insurance?

A

When there is more than one type of policy and one policy would be primary (first) and the other excess (secondary).

The vehicle policy is primary, the driver policy is secondary in most places. The policy wording will determine the order.

64
Q

What does ORP stand for?

A

Ordinary, Reasonable, Prudent person

65
Q

What is “no-pay, no-play”?

A

Applies in some states where if an injured or damaged party does not have insurance and is therefore not entitled to recovery from the at-fault party.

66
Q

What is the Free Public Services doctrine?

A

A common law doctrine that denies recovery against a tort-feasor by a governmental agency that has incurred costs in remedying the public health or public safety hazards caused by the tort-feasor’s negligence.

e.g. A train being derailed because the railroad was negligent in maintaining its track.

67
Q

What is “Burden of Proof”?

A

the obligation to prove one’s assertion.

Basic Claims Training (1 decks)

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