Process & Procedures

Process & Procedures

1. Meeting with PH or phone contact to resolve claims?

   • Telephone Adjusting
     • Pros
       • resolved quickly & economically
       • no travel costs
     • Cons
       • Higher risk of file leakage
       • missed opportunity to size up the claimant
         • risk of fraud going undetected
         • exaggerated claims not controlled
         • claims made be overpaid
       • high travel & equipment costs
   • Personal Visits
     • verification of facts
       • single loss v. pre-existing damage
     • Pros
       • adjuster can pass on info to UW
     • situations that merit visit
       • Complex claims
       • severe losses
       • losses not covered
       • subro. opportunity
       • a comittment to high level service
   • Use of IAs v Staff Adjusters
     • Criteria for outsourcing
       • locations where there is insufficient volume of claims to justify staff adjuster
       • during busy claims periods where claims overwhelm staff
       • during vacation time periods, or during cat. events
       • specialty lines of business may require expert assistance
     • Role of the Examiner
       • the examiner oversees the IA
       • leads the investigation & critically examines the adjuster's activities
         • approves any costs
         • outlines scope & terms of the assignment
           • provides instructions on coverage
             • explains what is expected
               • analyses IA reports
                 • determines what further action is required
                   • ensures the file is well documented
                     • ensures policy conditions are applied
       • is responsible for all decisions

2. Claims Reporting Systems

   • insured seeks the following from adjuster following report of claim:
     • guidance on claims process
     • reassurance
     • general support
     • is my claim covered?!
   • Broker involvement
     • FNOL
     • identify the policy that applies
     • brokers may have claims handling authority
   • call centres take FNOL

3. Handling guidelines incoming loss reports

   • prompt assignment of claims
   • triaging / allocation
     • which claims team to handle (Casualty/Property)
       • which adjuster (TA, Roadie?)
   • defining modest losses which will determine which adjuster will be assigned
     • complexity
     • location of loss
     • specialised knowledge required?
     • certain type of damage?
     • extensive damage?
     • A TA can be assigned and hire an IA on a limited assignment
     • appraisers and other experts can be brought in to assess and report

4. increasingly complex claims may warrant help being requested

   • increasing claim severity
   • lack of proper documentation
   • coverage issues
   • suspicious or inconsistent info. suggesting the claim should be carefully scrutinised
   • selection of various experts

5. Role of the appraiser

   • retained to inspect damage to autos, other property
   • identify the damage & price out the repairs
   • determine ACV, Market Value, Salvage

6. Claims File Documentation

   • Claims Manual ?
     • pros & cons
       • can become outdated
         • not followed
           • third parties using non compliance against the insurer
       • can be a good resource outlining expectations and how to
       • misconstrued or misinterpreted and outweighs the benefits
   • paperless systems
   • date stamping

7. Claims Handling Guidelines

   • vary based on the nature of the claim & its severity
   • differences for liability v. property claims
   • decision making roles
     • Manager support for approval
   • admin support
   • coverage analysis
     • interpretation of wordings
     • document the file to show how decisions were made
   • Reserving
     • changes supported by evidence
       • approval obtained as required
   • Reporting to Others
     • Re-insurance reporting issues
       • per agreement
     • government reporting requirements
     • action in case of fraud
       • referral to Special Investigations Unit
     • underwriting department
   • Investigation
     • timely to preserve evidence
     • guidelines for statements
   • Evaluation
     • reference material needed?
       • expert reports
       • scope & estimates
       • invoices
   • Negotiation & Settlement
     • well prepared after examining the facts
     • Can it be settled outside of litigation ?
   • Recovery Opportunity?
     • if any, refer to NRU

8. Auto Total Loss Practices

   • Coverage analysis applied
     • policy in force at time of loss?
     • policy covers the auto that was stolen?
     • policy covers auto against theft?
   • statutory conditions apply
     • appraisal
     • reporting theft to police
   • Investigation Applied
     • loan / lease docs?
     • certificate of title (ownership) of auto
     • location of all keys before and after theft
     • names and contact info for all who had access to auto
     • description of the auto, including mileage, options & service records
     • receipts for upgrades
     • finance & leasing contact info
   • Evaluation applied
     • Year, make, Model
     • factory options
     • Mileage
     • condition of exterior, interior, mechanical and tires
     • any other characteristics affecting value
     • ACV determined
   • recovered autos
     • cost of repairs to be determined
     • ACV
     • salvage
   • Negotiation & settlement Applied
     • Rental car expenses covered
     • offered on ACV
     • timing is usually longer for stolen autos due to police involvement

9. Claims Data Management Processes

   • data to be accurate and efficient
   • integration of systems
     • coding to identify type, location, of loss and other details
   • consistency
   • Loss Runs produced to show
     • files showing negative reserves
     • reserves by claim type
     • number of losses on policy on any given period
     • identify duplicates

10. File Retention

    • is costly and annoying
    • Privacy Laws dictate how and when types of personal data can be destoyed
    • Tax law requirments