TCR2-Preschool Final Flashcards
How are meniscal tear generally caused?
Twisting or turning quickly with foot planted and knee bent
Define negligence
Failure to exercise the standard of care required by law to protect others from harm
What is the period in which a lawsuit or a claim resolved after a loss?
Statute of limitations
Who is barred from recovery in a “not greater than” comparative negligence state?
Person who is 51% or more negligent
Who is barred from recovery in a “less than” comparative negligence state?
Person who is 50% or more negligent
Who is barred from recovery in a pure comparative negligence state?
No one unless you are 100% negligent
Who is barred from recovery in a contributory negligence state?
Anyone who has any negligence
What does the Company agree to pay in the Family Auto Policy under section 1?
We will pay damages for bodily injury or property damage for which any covered person becomes legally responsible because of an auto accident
Describe chondromalacia
Runner’s knee
Pain and swelling at front of the knee especially over and around the kneecap
What is GEICO’s policy for settlement of claims?
Settle all claims fairly and promptly
What is an example of a collateral source?
Worker’s compensation
Health insurance
PIP/MedPay
What does it mean when the patient has a “soft tissue injury-sprain/strain?
Damage of muscles, ligaments, and tendons
One off blow resulting in a contusion
What is the most common used method for treating soft tissue injuries?
Rest
Ice
Compression
Elevation
You have completed a coverage investigation and found that the insured violated a condition precedent to coverage, after receiving approval what would you send?
Disclaimer
Damages intended to punish the wrongdoer is what kind of damages?
Punitive damages
The wrongful act of two or more individual last combined to produce a single result is called a
Concurrent tortfeasor
Explain why the FTCA is important to insurance companies
Federal Tort Claims Act
What is a dermatome?
An area of skin supplied by the cantaneous branch of a spinal nerve
Ligaments connect what to what?
Bones to bones
Tendons connect what to what?
Connects muscle to bone
What is function of cartilage
Flexible connective tissue
Can bend but resist stretching
Provides support
Sliding area of joints
What is a DJ and describe why it would be used
Declaratory judgment
Ask courts to decide the parties’ obligations under insurance contracts
What is misrepresentation for claims purposes?
Misstatements given to the company to induce it to write a policy
What is the initial task of an examiner?
Verify proper coverage
When should a feature be established?
As soon as it is probable that a claim may be made
What are the primary duties of an attorney?
Advise & counsel
Prepare legal instruments
Perform services in courts of justice
What file contents can be released without the consent of the insured?
Property damage estimates/appraisals/repIr bill on insured’s vehicle to support our subrogation claim
Medical bills, lost of wages or income statements of insured when it is necessary to support our subrogation claim under MedPay, PIP or UM
Requests from government agency or by a valid subpoena properly served on us (Claims Legal must be consulted before complying)
What is a lien?
Charge or encumbrance upon property
What formula does GEICO use to evaluate claims?
No formula
We use judgment and experience
What type of damages is pain and suffering?
General damages
Grade 1 Sprain
Mild
Slight stretching and some damage to the fibers of the ligament
Grade 2 Sprain
Moderate
Partial tearing of the ligament
Abnormal looseness in the joint
Grade 3 sprain
Severe
Complete tear of the ligament
Causes significant instability and makes joint nonfunctional
Tendinitis
Inflammation or irritation of a tendon or covering of tendon
Bursitis
Bursae are small jelly like sacs located throughout the body
This is inflammation of bursa
MRI
Uses a strong magnetic field around the patient and pulses of radio waves sent from a scanner
Can take 30 minutes
Is more costly than a CT scan
CT scan
Uses radiation
Is cheaper than MRI
GEICO’s policy for settling claims
Settle claims fairly and promptly
As per claims manual, what is the company policy about paying claims?
It is as wrong to pay claims we should not be paid as it is to not pay claims which should be paid
What is the basic responsibility of a claims adjuster?
Act in a professional manner that will reflect positively on themselves and the companies
Equitable outcome
Who does the responsibility of the proper disposition of the claim rest on?
The claims associate who is assigned the claim
The only products we have are
Service
Protection
Who can waive statue of limitations?
VP of Claims Home Office
AVP of Claims Home Office Legal
Who should the claims associate deal with once a letter of representation is received?
The attorney
When should the claims examiner settle a claim?
As promptly as possible
Earliest practical time whenever possible
What is a reserve?
Dollar amount that the company can reasonably expect to pay for a completed settlement of the claim, including anticipated allocated expenses
Claim reserves must be established on what?
Probable costs based on present values
When should a reserve be established
As soon as it is probable that a claim may be made
When should a reserve be adjusted
Timely as the facts of each case warrant
2 types of reserves
Average
Case
Average reserve
Actuary determines average reserve amount by calculating actual loss experienced under each coverage
Care reserve
Requires establishment of a dollar reserve under each feature
Reserves should be changed if the value of the claim changes by:
$300
What would you do if the BI exposure on a claim was more than $50,000?
Place a case reserve on all exposures
When is the claims examiner responsible for the accuracy of reserves?
Every time you are in the file
When are property damage features changed to case reserves?
When expected expenses are $10,000 or more
What 3 pieces of information are needed to establish accurate BI reserves?
Detailed facts about the precise nature of injuries
Treatment
Prognosis
Parts of C71 summary
Loss description Coverage Liability Damages Course of action
What does IBNR mean?
Incurred but not reported claims
Claim files that have not been established although the accident or loss has occurred and we may or may not have the report at the company
Determined by the actuary
The key to coverage decisions making is ______ and _____ investigation
Prompt and appropriate
Who should be consulted for permission to deny coverage?
RLA
Claims home office attorney
Two types of coverage questions
No company policy on force at time of loss
Policy in force but the loss is not covered by that policy under the particular factual situation
5 types of coverage questions
Policy expiration and cancellation Is the vehicle covered Is the driver or passenger covered Is it a covered loss Has the insured can't movies with the policy conditions
Cases involving permissive use issues, which involve personal injury must be seen by the
RLA
2 types of driver exclusions
Voluntary
Involuntary
What is a waiver?
Relinquishment of a known right
What is estoppel?
May prevent a valid denial or disclaimer of coverage if the company fails act or acts in such a manner that would lead the insured to believe that coverage was in order or the insured acts to his/her detriment in reliance on that belief
What is an ROR and when should it be sent?
Informs insured that a coverage question has risen concerning his/her claim and that we require time to fully investigate the question
No significant delay to send
Types of special damages
Loss of earning
Medical expenses
Loss of services of child or spouse
What is loss of consortium and who is normally involved?
Sex
Society
Services
Spouse
A claim for pain and suffering is a example of
General damages
Property damage consist of
Damage to car
Loss of use
Damage to other property
An injury the claimant was treating for prior to the loss is an a half example of
Pre-existing injury
GEICO adjusters use ____ and _____ when determine fair settlements
Judgement and then experience
2 types of Compensatory Damages
General
Special
Rule of certainty
Requires plaintiff to establish his or her damages, without recourse to speculation or conjecture and must offer evidence as to exactly what damage he or she is claiming
A defendant would be held responsible for an injury that is superimposed over a pre-existing injury
A defendant would be held responsible for an injury that is superimposed over a pre-existing injury
What are the 3 measurements that must be made with respect to permanent disability cases?
Value of the medical attention that the person may have for the rest of his/her life or for the period of time that it would be necessary
Value of the impairment to his/her enjoyment of life
Value of the loss of earnings capacity
Medicare is what type of lien?
Super lien
A workers compensation carrier claim is neither a federal Leon nor a subrogation claim.
A workers compensation carrier claim is neither a federal Leon nor a subrogation claim.
The rule of certainty would apply to a situation where the plaintiff claims, as an item of damage, the value of lost opportunity, such as an opportunity of employment or contract
The rule of certainty would apply to a situation where the plaintiff claims, as an item of damage, the value of lost opportunity, such as an opportunity of employment or contract
Where in the Family Auto Policy can yo find information about the insured’s policy confirming to the state statutes?
Section V
General Provisions
Paragraph 12
