Short Answer Flashcards
Define Insurance Fraud
• Any act or omission with a view to illegally obtaining an insurance benefit
different categories of policy conditions relating to fraud (My Mom Told Ron F*** Not Eating)
- Misrepresentation
- Material change
- Termination
- Requirements after loss
- Fraud
- Notice to police
- Entry, Control, Abandonment/salvage
Waiver Example
: there is a fire in an apartment. The insured has renter’s insurance and provides information necessary to settle claim to recoup his loss. Once the claim is settled, the insured cannot pursue further action against the insurance company for settlement
Estoppels Example
A landlord might inform a tenant that rent has been reduced, for example if there was construction or a lapse in utility services. If the tenant relies on this advise, the landlord could be stopped from collecting the full rent
• Non-waiver agreement Example
a client drove while not having a driver’s license. The adjuster should stop interviewing the client right away when he finds out that information and ask client to sign a non-waiver agreement. The adjuster explains verbally to the client that not having a license is a breach of policy condition and puts coverage in jeopardy. If the client refuses to sign the non-waiver agreement, then the adjuster immediately stop investigating the claim further and gives the insured a reservation of rights letter to the client stating all of the above- that the client refused to sign a non-waiver agreement and why the adjuster does not believe there will be coverage
reservation of rights letter Example
By sending reservation of rights letter to the insured, the adjuster would be protecting the insurance company and would have avoided estoppels. The letter would also state that the investigation may conclude that the insurer reserves the right to deny coverage to the insured or to anyone claiming coverage under the policy
is an insurer’s notification to an insured that coverage for a claim may not apply
reservation of rights letter
is an agreement signed by the policy holder after a loss, agreeing that the investigation and determined of the amount of damage by the insurance company shall not be constructed as an admission of liability
• Non-waiver agreement
is a bar created when someone by his action, or lack of it, indicates that he will not exercise a right he has. He tops himself from exercising his right later.
estoppels
is the intentional and voluntary relinquishment of a known right. A waiver under a policy is required to be clearly expressed and in writing
• Waiver
is being responsible for providing the principal with all information that materially affects the principal’s interests; all of the information that is relevant to the affairs entrusted to the agent
Fiduciary duty
• Burden of proof
The standard by which a claim must be proven to prevail. The burden of proof is typically borne by one party or another
• Standard of proof
The test to establish whether a party has succeeded in proving a fact in issue. Standard of proof in civil matters is generally “on balance of probabilities” or a “preponderance of the evidence”, meaning that if it is likely that the fact is true, then the standard has been met.
The test to establish whether a party has succeeded in proving a fact in issue. Standard of proof in civil matters is generally “on balance of probabilities” or a “preponderance of the evidence”, meaning that if it is likely that the fact is true, then the standard has been met.
• Standard of proof
The standard by which a claim must be proven to prevail. The burden of proof is typically borne by one party or another
• Burden of proof:
different types of evidence
Direct Evidence Circumstantial Evidence Sworn Statements Expert Evidence Testimony given under oath Documents Experiments Real Evidence Spoliation
Proves the fact in issue without the need to infer or make presumptions
• Direct Evidence
Direct Evidence
Proves the fact in issue without the need to infer or make presumptions
• Circumstantial Evidence-
is based on making inferences form connected facts
is based on making inferences form connected facts
• Circumstantial Evidence-
• Sworn Statements
from witnesses or the insured are the most common form of evidence. There are some instances when unsigned ( unsworn) statements will be accepted by the courts
from witnesses or the insured are the most common form of evidence. There are some instances when unsigned ( unsworn) statements will be accepted by the courts
• Sworn Statements
• Expert Evidence
- on scientific, technical or professional matters given by qualified persons who can speak authoritatively on a particular subject. Experts may also qualify to give opinion evidence based on the special knowledge or skill they possess.
- on scientific, technical or professional matters given by qualified persons who can speak authoritatively on a particular subject. Experts may also qualify to give opinion evidence based on the special knowledge or skill they possess.
• Expert Evidence
• Testimony given under oath
by witnesses at trial is a common method to bring evidence before the judge. The Latin term viva voce is used to identify this type of evidence
by witnesses at trial is a common method to bring evidence before the judge. The Latin term viva voce is used to identify this type of evidence
• Testimony given under oath
- such as written contracts, deeds, share certificates and other similar items may be eligible to be presented as evidence
• Documents
• Documents
- such as written contracts, deeds, share certificates and other similar items may be eligible to be presented as evidence
are sometimes conducted in court by experts. The judge decides whether or not to allow such an event in the courtroom
• Experiments
• Experiments
are sometimes conducted in court by experts. The judge decides whether or not to allow such an event in the courtroom
such as a physical object can be brought before the court. This may include photographs, videotapes, audiotapes, or any article. Electronic records have generally been accepted by courts. To introduce electronic evidence, the integrity of the electronic document must be shown. The record-keeping must be shown to be reliable.
• Real Evidence
• Real Evidence
such as a physical object can be brought before the court. This may include photographs, videotapes, audiotapes, or any article. Electronic records have generally been accepted by courts. To introduce electronic evidence, the integrity of the electronic document must be shown. The record-keeping must be shown to be reliable.
• Spoliation
of evidence refers to its destruction before the case comes to trial
of evidence refers to its destruction before the case comes to trial
• Spoliation
