TCR2 Final Review Flashcards
If property damage claim is paid at 100%, does this mean we have to pay the bodily injury claim at 100%?
No
Acceptable reasons for overall bypass consultations
Opened in error
No coverage
Understand CBP for uninsured claims
CBP is the uninsured person/driver
Unknown person
Four criteria needed in CIQ for recommendation of pain and suffering
Diagnoses
Impact on lifestyle
Venue
Evaluation
Where do you enter your review of the medical records
Evaluation tab
Save to conduct page by clicking add to strategy
Submitted specials “other” category includes
Childcare Housekeeping Mileage Transportation expenses Other expenses related to the claim
Bad faith claims can arise from
Failure to act fair, prompt and reasonable
Failure to inform of coverages
Failure to explain denial/disclaimer
Extra-contractual damages
Awarded against insurance companies for bad faith
Can include attorney fees, interest, costs, and consequential damages
What can occur if you increase your offers without justification?
Bad faith
Suggests that the first offer was not fair and reasonable
Where do most all states Unfair Claims Practice laws originate from?
Model Act
NAIC
What is a time limit demand?
Gives a specific amount of time to respond
What situations would an offer of policy limits be appropriate and what would you need to explain to the insured?
Obvious injury that exceeds limits
Advise insured of policy limits
Advise insured they can hire an attorney at their own expense
Advise insured they have the right to contribute to the claim
What are general damages
Inconvenience
Pain and suffering
What are special damages?
Out of pocket expenses
Have to be substantiated
How does GEICO determine the value of a claim?
Judgement and experience
When aggravated liability is involved, what should the insured be informed of?
Policy limits
Possibility of punitive damages
We typically do not pay punitive damages
Explain loss of consortium
Loss of sex, society or services
Spouse or dependent can claim
Derivative claim
Explain loss of earnings capacity
Difference of having to take a lower paying position due to injuries
Factors for claims of permanency
Competent evidence for allegation of suffering Permanent injury AMA guidelines Testimony of treating physician Physician's reputation
Factors for claims of scarring
Future enjoyment of life Does it affect the ability to work Masking factors Can scarring be improved through plastic surgery Cosmetic value Age Gender Occupation Marital status
Examples of collateral source
No fault coverage PIP/MedPay Worker's Compensation Sick leave Health insurance
What is the release for UM/UIM?
Release in trust
What is general release?
Release in full
Normal release
Typical method providers use to document findings.
Subjective - patients complaints
Objective - examination/ findings
Assessment - diagnosis
Plan - treatment plan
ROS
Review of systems
MMI
Maximum medical improvement
State where condition cannot be improved or when treatment has plateaued
ADL
Activity of daily living
Functional mobility
Personal care
Inability to do causes a self-care deficit
DTR
Deep Tissue Reflex
Reflex hammer
Test reflexes
Motion palpitations
Chiro uses hands to touch/feel the motion of specific segments of the spine while the patient moves
Osteoarthritis
Joint thinning
Spondylolisthesis
Forward displacement of vertebrae one over another
Stages of soft tissue injury
Acute inflammatory
Repair
Remodeling
Acute inflammatory phase
Pain Swelling Redness Warmth From time of impact to 72 hours Passive modalities
Repair phase
Beginning of active modalities
Remodeling phase
Shift from passive/active modalities to active modalities
Radiculopathy
Compression or irritation of a nerve as it exits the spinal column
Conservative treatment
Can resolve within 6 weeks to 3 months
Most common in lumbar and cervical
Dermatomes
Area of skin mainly supplied by a single spinal nerve
Medicare is what type of lien?
Super lien
Desktop activities best practices
Complete what is due today first Create a plan of action Limit one activity per claim Avoid setting entries for Monday Follow appropriate time lines
What is the sole purpose of your action plan?
Move file toward closure
Phases of negotiation
Preparation
Opening - build rapport before making initial offer
Bargaining - goal is win-win
Closing
Ways to approach a rejection of an offer
Ask injured party for a dollar figure they feel the claim is worth
Ask why they should receive more
Support your offer by going through the strengths/weaknesses
Explain why the injured party demand is different/unrealistic/unwarranted
Do not jump automatically or increase offer without justification
When is it appropriate to offer a first call settlement?
Treatment minimal
Unrepresented
When can you use oral releases?
Unrepresented
Less than $5K
1st call settlement
$1,000/$1,500 without medical documentation
When can you not use oral release?
Open-ended Modified Minor children Uninsured Under-insured Is attorney represented
CHO guidelines for 1st call settlement and early resolution
Treatment is minimal
3 days within determining liability and discussing settlement
Define negotiation and what is the goal?
Confer with another so as to arrive at the settlement of some matter or to arrange for or bring about through conference discussion and compromise
Means by which parties seek a settlement that is agreeable to each with the utmost of good faith and fair dealing
Agreement not victory
Tools to help reduce BI on case life
Aggressive and thorough follow up
Lack of interest process
Follow proper HIPPA usage guidelines
Online forms and e-signature
What is the lack of interest process?
Day 1-10
2 contact attempts and letter
Day 10-20
2 contact attempts
Day 20
Send LOI letter
Day 35
Close
BI process
Injured claimant Treatment BI Process Obtain Authorization HIPPA Request Meds Evaluate and Settle
Under 5K - oral release
Over 5K, Minors, UM/UIM - written release
