Chapter 2 Adjuster Duties & Reponsibilities

Adjusters Job Description

1. Contact Policyholders/claimants for relevant information, accurately evaluate and process claims 2. Evaluate Claims, eligible or not 3. Finalize Claims, completing research and/or requesting further information from providers, policyholders, other parties 4. managing pending (open) files 5. work closely and effectively with other members of the team, all claims matter, resolved in a timely manner

Loss Adjustment Process

1. policyholder/agent reports a loss to insurer 2. claim department assigns claim to adjuster 3. claim begins adjustment process, by making contact with policyholder

elements of good service

1. proactive approach to claim handling 2. timely follow up 3. complete tasks as promised 4. effective communication (good listener)

Adjusters Ethical Considerations

1. shall not directly/indirectly refer or steer any claimant needing repairs to any person with whom the adjuster has undisclosed financial interest, anticipate compensation for the referral 2. threat all policyholders/claimants equally 3. adjust all claims in accordance with terms/conditions of contract. let the policy do the talking 4. shall not approach investigations prejudicial to the policyholder, open-minded, facts do the talking 5. handle every adjustment/settlement with honesty/integrity, fair adjustment/settlement 6. make truthful/unbiased report relating to all claims, complete/thorough investigation 7. exercise extraordinary care with elderly/disabled clients, not disadvantaged, by failing memory/impairment 8. act with due diligence, proper disposition of the claim 9. not advise a claimant to refrain from seeking legal advice 10. not engage in the unlicensed practice of law 11. always work in good faith to obtain a fair/equitable claim settlement

Adjustment process checklist

1. verify the policy information 2. contact and meet with the insured 3. inspect the property and damages thoroughly 4. examine any pertinent documents and reports, such as a police report 5. review prior losses 6. analyze coverage and either settle/deny the claim

General Damages

A monetary award to compensate a victim for losses, such as pain and suffering, that do not involve specific measurable expenses.

Adjuster

A representative of an insurance company who investigates and acts on the behalf of the company to obtain agreements for the amount of the insurance claim. must understand and follow their duties in order to be considered a true professional, a customer service profession. focused on providing exemplary customer service

Independent Adjuster

An independent claim representative who handles claims for insurers for a fee. receive their assignments from an adjusting firm. Firm pays the fee

when the insured and insurer disagree on the amount of money that is to be paid on a claim, either side can request this form of dispute resolution

Appraisal process

what is the method of resolving disputes that comes to play when there is a dispute regarding the interpretation of the insurance contract to if something is covered or not

Arbitration

Claim Activity Log

Claim Diary - clear, concise, factual, always up to date

Staff Adjuster

Employee of the insurance company's claim department.

Closing Report

Gives the complete summary of all the facts and settlement of the claim.

what type of adjuster provides services on a contract basis to insurance companies, self-insured firms and governmental agencies

Independent Adjuster

this type of adjuster report gives the results of the Initial Investigation

Initial Report

Adjuster Reports

Initial, Interim, Closing Reports every 15-30 days after initial claim keeps the company advised on status of investigation/adjustment. to make recommendations, request assistance, settlement authority if the amount exceeds adjuster authority. is adjuster giving appropriate attention, timely manner

these agreements are usually used when there are coverage questions or when there may be an unusual delay in verifying coverage or when the loss is very serious

Non-Waiver Agreements

what type of adjuster represents the interests of the insured

Public Adjuster

The type of damages are awarded when the injury was caused by the gross negligence of the defendant?

Punitive Damages

This notice informs the claimant of the policy coverage questions and reserves the rights of the company while the claim continues to be investigated?

Reservation of Rights

These types of damages consist of medical expenses and lost wages?

Special

and adjusters investigation should determine ___________ about what caused the loss, how coverage applies, and the amount of the loss

The Facts

Replacement Cost

The cost to repair or replace property using new materials of like kind and quality with no deduction for depreciation.

Punitive Damages

awarded when injury was caused by gross negligence, triple the amount of General Damages, usually not covered by insurance. Punishment

Adjusters Job

carrying out research on records, medical and police, performing inspections on the property, interviewing any possible witnesses. follows a set of general claim and statutory guidelines, investigating policy coverage, damages, liability as quickly as possible. attends both internal/external customers by phone or written correspondence

Open-end Release

claim remains open for payment of any future special bills, such as medical bills

Compensatory Damages

compensate, repay, for the loss suffered. Special and General Damages

Non-Waiver Agreement

coverage questions, there may be an unusual delay in verifying coverage, serious loss

Diminished Value

difference between a vehicles value before a collision loss and value after the repair. affects resale value

Arbitration

dispute regarding the interpretation of the insurance contract, something covered or not. impartial 3rd party known as an Arbitrator. insured/insurer agree in advance to abide by the arbitrators award, both parties have a chance to be heard

Appraisal

either party may make a written demand for the appraisal process. is a dispute over amount of claim. each party can choose an appraiser then selects an Umpire to make the final decision. each pays their own appraiser, then share the Umpire fee

Evaluation

facts investigated, value of the claim. Property, either Replacement Cost or Actual Cash Value

General Release

immediate payment. claimant extinguishes all future claims

Initial report

initial investigation

Reservation of Rights Letter

insured party refuses to sign a Non-Waiver Agreement, adjuster sends out a Reservation of Rights Letter by Certified Mail. serves as the Non-Waiver Agreement, informs claimant policy coverage is in question, while the claim is being investigated

Interim report

interval reports, status of claim. status of estimate, additional medical information, any other type of information

Adjuster Duties

investigate insurance claims, find out the extent of liability, how much is to be paid

Investigation

investigate, inspect, assess, value of the loss. basis of every claim. should not be assumed, but rather determined by all the facts in support of a rational conclusion

Adjusters obligation

investigate, verify the cause of loss. sometimes cause will be clear, coverage determined easily. other cases cause of loss may require an extensive investigation.

Initial Contact

listen, display professionalism, express empathy, respectful tone. be sensitive, allow policyholder to tell their story, show concern and thoughtfulness. be a guiding force through the claim process without being overly forceful. policyholder is going through a traumatic event, looking for adjuster to be knowledgeable, respectful, compassionate. policyholder may consider the loss as a major disruption may have never made a claim before, first time to see insurer, many do not understand their coverage, adjuster must take time to explain and meaning in relation to the loss

Special Damages

medical expenses and lost wages. out of pocket expenses. exact and verifiable figure

Mediation

negotiation between 2 or more parties facilitated by a neutral 3rd party known as a mediator. adds structure to simple negotiations, offers parties an opportunity to create a process that suits the nature and size of their claim, an objective and respected neutral 3rd party. chances the parties reach common ground. they do NOT issue rulings, make decisions that are binding. Instead, they attempt to create an environment likely to result in a settlement

Privacy

policyholders privacy, ethical responsibility. area of increasing liability. highly personal information, extreme care, keeping their information private/secure

Documentation

proper claim handling, to achieve positive results. detailed log of all claim activity. gathering records, photographs, taking statements, preparing damage scopes and estimates

Public Adjuster

represents the insured, negotiates the settlement with insurers claim representative and is paid a fee based on the amount of the claim settlement

Adjusters Investigation

should determine the facts, what caused the loss, how coverage applies, amount of loss

after receiving the claim assignment and reviewing the initial report, the adjuster should contact ________________ and begin their investigation

the Insured/Policyholder

3rd Party or Liability Claims

the amount of property damage, seriousness of injury, medical treatment, injury completely healed

Actual Cash Value

the payment you receive is based on the replacement cost of an item minus depreciation