Study 5 Flashcards
What steps are involved in the claims process?
Insured reports loss to broker, agent or insurer
Claims handler records prelim info and asks for details, insured may complete questionnaire
Claims info is reviewed by claims handler or AI software; which policy or policies apply to the property or incident? Does the policy period cover the loss? Is the cause of loss potentially covered?
Claims handler identifies possible coverage issues that will require investigation/review
If broker is involved, may accept loss report and pass this along to insurer of record
Loss adjuster is assigned the claim and proceeds
What steps does the loss adjuster follow once taking over the claims process?
1) Verifies coverage
2) Investigates the loss
3) Evaluates and assesses damage
4) Negotiates as necessary or denies the claim
5) Arrives at a settlement
6) Recommends payment
7) Pays the claim
[VINEARP]
What are other key functions of the claims process?
Investigate to gather required info and document the loss
Evaluate the amount of damage
Negotiate and agree upon the value of the insured damage
Settle the loss
What are the ways an insured may report a claim?
Call or visit the offices of the insurer, broker or agent
Email the broker, agent or insurer
Use a web based form provided
Use an app
When customers report losses to their agent or broker, what is the effect of the report?
The report is deemed to be notice to the insurer.
What is the role of call centers in the claims process for some insurance companies?
Call centers take the first notice of loss (FNOL) directly from the insured, eliminating the need for brokers or agents.
How must the call centers front-line staff be prepared?
Front-line staff must be prepared to handle a variety of situations, including simple inquiries, complaints, or disputes. Some insurers require complaints to be referred to a supervisor or manager.
What are the advantages of using a digitalized FNOL system for adjusters?
Faster claims settlements
Reduced claims adjustment costs.
Can a policy be assigned to another party without the insurer’s consent? Under what circumstances?
A policy cannot be assigned to another party without the insurer’s consent.
However, upon the death or bankruptcy of the insured, the insurance continues in favor of the heir, trustee in bankruptcy, or remaining insured, subject to the same conditions that were applicable to the named insured.
(If the beneficiary of the contract is other than the named insured, the same condition applies.)
What are some examples of supporting service providers?
appraisers, estimators, and surveyors; restoration contractors, automobile body shops, and forensic accountants
authorities such as police and firefighters;
witnesses; doctors and rehabilitation service providers; private investigators;
lawyers, arbitrators, and mediators.
What can supporting service providers help with?
1) Assess the damage.
2) Determine the cause of the loss.
3) Estimate the cost of repairs and carry them out.
4) Supply products or services.
5) Assist in resolving claim disputes.
[ADESA]
How can claims staff enhance their relationship with claimants and effectively respond to their needs?
Being flexible and responsive to the claimant’s emotional state.
Demonstrating a sincere desire to resolve claims promptly and professionally.
The use of tact and diplomacy helps reassure and calm claimants who have experienced a loss.
knowledge of the contract terms and a focus on the facts.
How can claims handlers manage the insured’s expectations effectively during the claims process?
> Conveying a realistic timeline for the claim process if possible, including when to expect contact and resolution.
Informing the insured of any coverage issues or applicable deductibles as soon as possible.
Pointing out relevant policy conditions and limitations at the time the claim is reported.
Writing detailed letters summarizing these points and regularly updating the insured with written correspondence, such as letters and emails, and through direct communicatin
When there is doubt that a claim is covered, what may the loss adjuster do?
consult with more senior claims people or,
if necessary, engage coverage counsel to provide a legal opinion.
What is the Insured’s Duty to Report the Loss
the insured must report the loss to the insurer as soon as possible / as soon as they have been given notice or become aware of a potential liability claim
