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Flashcards in Ch 7 Deck (100):

What are the two primary goals of the claim function?

1) Complying with the contractual promise
2) Supporting the insured's financial goals


How does the claims department help the insurer comply with the contractual promise?

By providing fair, prompt, and equitable service to the insurer, either (1) directly, when the loss involves a first-party claim made by the insured against the insurer, or (2) indirectly, by handling a third-party claim made by someone against the insured to whom the insured might be liable.


How does the claims department support the insurer's financial goals.

By managing all claim function expenses, setting appropriate spending policies, using appropriately priced providers and services, and ensuring fair claim settlement.

Success in achieving its financial goal is reflected in its reputation got providing the service promised.


How does marketing use information from the claims department?

Marketing needs information about customer satisfaction and timeliness of settlements.

The claim handling process can also be a source of new coverage ideas and product innovations for niche markets.


How does information from the claims department assist producers?

Helps producers explain premium changes as claims usually affect renewal premium.

Claims also informs producers of court rulings that affect the insured's loss exposures or pricing. (Ex. Interpretation of policy exclusions or application of limits)


How does the claims department assist underwriting?

Proper, consistent, and efficient claim handling enables underwriters to evaluate, select, and appropriately price loss exposures based on consistent loss costs.

When inspecting property, claims may point out information that underwriting is unaware of and underwriting can cancel coverage, request corrective measures, or adjust premium.

A number of similar claims could alert underwriting management to a problem with a particular class or type of insured or an adverse court ruling. This could be due to new technologies add by an insured (ex. Dangerous method of roofing)


How does the claims department assist actuarial?

Provide information on incurred losses.

Provide information on loss adjusting expenses and recovers me amounts associated with claims (salvage, reinsurance, subrogation, deductibles to be repaid by the insured)

When claim payments are recorded accurately and realistic reserves are set in the insurer's claim processing system, the raw data that actuaries use to develop rates will be accurate, and the rates will reflect the insurer's loss experience.


How does the claims department claims interact with lawyers?

Claimants hire attorneys. The insurer may also need an attorney. Claims will assist the insured's lawyer as needed by sharing claim details and assembling information that supports the insurers position.


How does the claims department interact with the public?

The claims department largely determines the insured's public image since they are the primary contact.

People involved in losses are emotional and the claims rep is their first contact. The claims rep must be empathetic.

Technological improvements have helped insured improve the quality and speed of claim service.


How does the claims department work with State Regulators?

Some claim representatives are subject to licensing. Regulators investigate complaints and perform market conduct investigation. Enforcement is handled through Unfair Claims Settlement Practices act.

Claim reps must respond to inquiries from the insurance department within a certain time frame or be subject to fines or loss of license.


An organization that provides administrative services associated with risk financing and insurance.

Third-party administrator.


Employees of an insurer who handle most claims. These include inside claim reps and field claim reps (outside claim reps).

Staff Claim Representatives


An independent claim representative who handles claims for insurers for a fee.

Independent Adjuster


Under which situations does an insurer use an independent adjuster?

Some use independent adjusters for all field work. Some use independents for overload, catastrophes, or special claims and some use independents when it is not feasible to set up claim offices in certain areas.


An organization or person hired by an insured to represent the insured in a claim in exchange for a fee.

Public adjuster


Incurred Losses

The losses that have occurred during a specific period no matter when claims resulting from the losses are aid.


An insurer's incurred losses (including loss adjustment expenses) for a specific period divided by its earned premiums for the same period

Loss Ratio


The portion of written premiums that corresponds to coverage that has already been provided.

Earned Premium


An insurer's incurred underwriting expense for a specific period divided by its written premiums for the same period

Expense Ratio


What is the formula for the combined ratio?

Loss Ratio + Expense Ratio


What are three of the more frequently used measures to gauge claims department performance?

best practices, claim audits, and customer satisfaction


A system of identified internal practices that produce superior performance. They are created by either studying the insurer's own performance or the performance of similar successful insurers and they are often based on legal requirements.

Best practices.


List the activities that provide a framework for handling claims.

-Acknowledging and assigning the claim.
-Identifying the policy and setting reserves
-Contacting the insured or the insured's representative
-Investigating the claim
-Documenting the claim
-Determining the cause of loss, liability, and the loss amount
-Concluding the claim


What does a claim rep send to the insured when it becomes apparent that coverage may not be available for a loss?

A reservation of rights letter or nonwaiver agreement.


What are the tasks completed in acknowledging and assigning the claim?

1. Acknowledge claim has been received
2. Assign the claim
3. Assign to a CR that has the skills to handle claim
4. Contact insured or third party


Nonwaiver Agreement

A signed agreement indicating that during the course of the investigation, neither the insurer nor the insured waives rights under the policy.


Reservation of Rights Letter

An insurer's letter that specifies coverage issues and informs the insured that the insured that the insurer is handling a claim with the understanding that the insurer may deny coverage should the facts warrant it.


What are the two methods of loss reserving that rely on the claim rep's judgment?

individual case and roundtable mehods.


A method of setting reserves based on the claim's circumstances and the claim rep's experience in handling similar claims? The reserves set by this method can vary widely by claim rep.

individual case method


This method of setting reserves by using the consensus of two or more claim personnel who have independently evaluated the claim file is time consuming so it is not usually used for initial reserves; it is suitable for serious or prolonged claims.

roundtable method


This method of reserving establishes a predetermined dollar amount of reserve for each claim as it is reported. It is usually used as the initial reserve and is modified within a specified number of days.

average value method


This method of reserving sets reserves using a mathematical formula.It is based on an assumption that ratios exist between certain costs such as the medical cost and indemnity (or wage loss) in a workers comp claim. It is frequently used to set the additional living expense reserve under a homeowners policy if a home is destroyed by fire.

Formula method


A method of setting reserves with a software application that estimates losses and loss adjustment expenses.

expert system method.


A loss reserving method that establishes aggregate reserves for all claims for a type of insurance. It is used to suggest standard reserves for similar types of claims or for a class of loss exposures. This method is suitable for claims that are reported long after the expiration date of a policy, for example medical malpractice.

loss ratio method.


What does the IBNR reserve usually also include an allowance for?

Reported losses for which the case reserves are judged to be inadequate and a reserve for claims that have been closed and then reopened.


When setting a reserve using the individual case method, which factors are examined?

1) Claimant profile (age, sex, occupation, education, dependents)

2) nature and extent of injury (permanency, pain &suffering?, lifestyle disruption)

3) special damages (quantified)

4) claimant representation

5) liability factors (negligence, comp neg?, legal limit to recovery (cap on certain damages)

6) misc. factors (economic conditions in geographic area), was insured's conduct outrageous, etoh/drug use?, insured's credibility as witness, claimant credibility as witness)


What happens if claims are not adequately and accurately reserved?

The ratemaking process could
be distorted and the insured's capacity could be reduced. If this continues, solvency could be threatened.


How are reserve errors caused?

Initial reserve may be inaccurate because they are determined based on limited information. Failure to review reserves could cause an error.

Poor planning, lack of expertise in estimating claim severity, or unwillingness to re-evaluate the facts. This can result in stairstepping.

Not anticipating inflation and ultimate cost of a claim that takes years to settle.

Overconfidence of ability to conclude a claim for a lesser amount.

Keying error.


What is stairstepping and which claims does it affect most?

Incremental increases in claim reserves by the claim rep without any significant change in the facts of the claim. This is a concern for claims that could remain open for many years. If new information comes to light and the reserve is increased, it is not stairstepping.


What purposes does initial contact with the insured serve?

Reassure the insured that the claim will be investigated.

Gives rep a chance to explain the process.


What should a claim rep do when making initial contact?

-give specific info to insured regarding protecting property and documenting the claim.
-describe inspection, appraisal, investigation.
-tell about additional investigation to resolve potential coverage issues. Tell insured about any additional information needed.
-explain potential coverage questions, policy limitations, exclusions and obtain nonwaiver agreement if necessary.
-obtain authorizations for medical/wage loss.
-explain how long it will take
-give blank proof of loss form and written instructions.


Voluntary or intentional relinquishment of a known right. Ex. Telling an insured claim is covered and then trying to deny.



This results when one party's action causes another party to rely on that behavior or those words with detrimental results. Ex. If insurer tells an insured that damaged goods can be discarded before they are inspected, they cannot deny the claim based on the goods not being available for inspection.



Which purposes do nonwaiver agreements and rors serve?

-advise the insured that any action taken by the insurer in investigating the cause of loss or in ascertaining the amount of loss is not intended to waive or invalidate any policy conditions.
-to clarity that the agreement's or the letter's intent is to permit a claim investigation and that neither the insured nor the insurer will thereby waive any respective rights or obligations.


When is a nonwaiver agreement usually used.

When the claim rep is concerned about investigating a claim before the insured has substantially complied with the policy conditions or when there appears to be a specific coverage problem or defense.


What are some of the different investigations that are done when investigating a claim?

1) Claimant investigation (statement)
2) Insured/Witness investigation (statement)
3) Accident scene investigation: can determine if accounts of the accident are plausible or questionable.
4) Property damage investigation: (confirm cause of loss or extent of damage)
5) Medical investigation (determine costs of medical treatment, expected duration of treatment and disability, the need for rehabilitation, and the suitability of medical care for the type of injury the claimant suffered.
6) Prior claim investigation (avoid paying for claims that were previously paid)


The process by which an insurer can, after it has paid a loss under the policy, recover the amount paid from any party (other than the insured) who caused the loss or is otherwise legally liable for the loss.



What happens if the insured breaches the subrogation agreement?

The insurer has the right to collect from the insured the amount that could have been recoverable from the responsible third party.


What elements must file status notes contain?

-Clear, concise, and accurate information.
-Timely claim handling
-A fair and balanced investigation considering the insured's and the insurer's interests
-Objective comments about the insurer, the insured, (shouldn't take sides or express prejudice) or other parties associated with the claim
-A thorough good-faith investigation


List examples of file reports that may be prepared by a claim rep?

-Preliminary reports required by some insurers within a certain time period from the report date. These acknowledge that the claim rep received the assignment, inform the insurer about initial activity on claim, note coverage issues, and request assistance. (24h or 7d or if open longer than 30d)

-Status reports: Tell insurer how claim is progressing on a periodic basis. Progress is recorded, recommended reserve changes are noted, requests for settlement authority.(every 15/30 days)

-Summarized reports: detailed narratives with a certain format. These are common when the home office needs to review a file. (ex. certain type of claims .. arson, potentially fraudulent claim) (usually within 30 days)

-External reports: inform interested parties about the claim and inform the public of the insurer's financial standing. Recipients include producers and states' advisory organizations,.


The Office of Foreign Asset Control requires all claim payors to check the master list of ________ and ________ before paying a claim.

potential terrorists and drug traffickers


What information should a claim denial letter contain?

Must comply with legal requirements. All known reasons for the claim denial. Policy language should be quoted and the location of such information cited. The policy provisions should be described in relation to the facts of the loss. The letter should also invite the insured to submit additional information that would give the insurer cause to re-evaluate the claim. It should be signed by the claim rep.


What are the most common ADR methods?

-Summary jury trials


ADR method by which disputing parties use a neutral outside party to examine the issues and develop a mutually agreeable settlement



A cost-effective ADR method by which disputing parties use a neutral outside party to examine the issues and develop a settlement, which can be final and binding (some states make binding).

The advantage of this method is that someone other than the insurer and the claimant decides the case.



Provide an example of when arbitration is commonly used.

When two policies issued by different insurers cover the same loss. One carrier settles and arbitration determines what each carrier owes.


ADR method which evaluates only the amount owed on a covered loss. Each party chooses an appraiser and the appraisers choose an umpire who makes a binding decision.



A non-binding ADR method by which a case undergoes an abbreviated version of a trial before a panel or an advisor who poses questions and offers opinions on the outcome of a trial, based on the evidence presented



What is the main advantage of mini-trials?

Claimants and insureds can learn the likely outcome of their cases without having to contend with delays in the legal system.


an ADR method by which disputing parties participate in an abbreviated trial, presenting the evidence of a few witnesses to a panel of mock jurors (selected from actual juror pool) who decide the case

summary jury trial.


What are the advantages of a summary jury trial?

Can be concluded in a short period of time, so legal costs are reduced. There are fewer witnesses so there are fewer fees. Attorneys are not needed as long as they would be for a regular trial so time to develop the case and prepare for trial is less.


Definition of "bad faith" according to Black's Law Dictionary:

An insurance company's unreasonable and unfounded refusal to provide coverage in violation of the duties of good faith and fair dealing owed to an insured. Bad Faith often involves an insurer's failure to pay the insured's claim or a claim brought by a third party


the failure, without legal excuse, to fulfill a contractual promises

Breach of contract


Some courts decided that insurers have an implied duty of good faith and fair dealing when settling claims, requiring insurers to value _____ ______ ______ at least as much as _____ ___.

Some courts decided that insurers have an implied duty of good faith and fair dealing when settling claims, requiring insurers to value their insureds' interests at least as much as their own.


Why have bad-faith claims arise more frequently under insurance-related contracts?

Because insurance contracts involve the public interest and require a higher standard of conduct due to the unequal bargaining power the insurer has in comparison to the insured as the insurer dictates the contract and controls handling of claims.


What is the first step in determining if an insurer acted in bad faith?

The standard of conduct to which the insurer should be held.


Which standards do courts use in determining whether an insurer acted in bad faith?

-negligence (some only award punitive damage if gross misconduct is determined)

-intentional and gross misconduct (intended the misconduct and consequences)

-look for signs of "dishonest purpose, moral obliquity, conscious wrongdoing ... some ulterior motive"


What are the elements of good faith claim handling?

-thorough, timely an unbiased investigation
-complete and accurate documentation
-fair evaluation
-good faith negotiation
-regular and prompt communication
-competent legal advice
-effective claim management


How does timely contact benefit the insurer?

-more likely to remember details
-parties at more likely to share information because they are reassured that their claim is important. They will be less likely to retain counsel or be swayed by others' advice.


What is the major goal of HIPA?

Protect individuals' health information while allowing the flow of information to provide high quality health care.


Under HIPA, when is an entity permitted to use and disclose health information without an individual's authorization?

1) when the info is disclosed to the individual.
2) when info is used in treatment, payment, and healthcare operations (ex. Sending medical records to another doctor)
3) when the individual is given the opportunity to agree or object to certain disclosures.
4) when the info is incident to an otherwise permitted use disclosure
5) in the interest of public health
6) as limited data for the purpose of research, public health, or health care operations.


Why do claim reps have to be aware of GLB?

It restricts their access to financial information obtained by the company for a purpose other than a claim which would useful by the claims department.


What effect does Sarbanes-Oxley have on the claims department?

Publicly traded companies have more extensive reporting of claim information, greater accuracy in setting reserves, and more extensive audits or claims and claim files.


Why do claim files have to be organized, comprehensive an accurate?

Many different parties need to review the claim file.

• Supervisor
• Peer audits
• State insurance regulators
• DA
• HO
• Broker, UW, regulators
• Mediators


What are elements of a fair evaluation?

-prompt evaluation as unfair claim settlement practices acts often specific time limits for evaluations of coverage and damage.

-prompt response to claimants, Insureds or lawyers, especially to a demand that is at or near policy limits. (May be willing to settle for policy limit if done promptly)

-based on facts, not opinions.


What are elements of good faith negotiation?

-make realistic offers based on evidence and documentation in claim file
-carefully consider all demands m
-don't allow egos and emotions to affect negotiations
-use policy provisions when applicable to resolve disputes over settlement.
-consider all forms of ADR


What results does regular and prompt communication with the insured accomplish?

-insured feels like part of defense and can offer assistance.
-insured can participate in discussions about the possibility of settlement and the handling of the claim
-the correspondence documents good faith claim handling
-correspondence established that the insured gave the insurer informed consent to take on the defense of the case and to decide how to defend it.


Following the advice of competent _______ can be considered evidence that an insurer acted in good faith.



What are the three crucial duties involved in claim management?

-Consistent supervision
-Thorough training
-Manageable caseloads


How is consistent supervision demonstrated?

-Notes in claim files documenting reviews
-Managers becoming involved in settlement evaluation and strategy when the claim rep's authority is exceeded


How do claim managers help maintain an insurer's underwriting profit?

By managing all claim function expenses, setting appropriate spending policies, and using appropriately priced providers and services.


An insurer's management is concerned with garnering the goodwill of the public. Explain how the insurer's claims department could devise a philosophy that would address management's concerns and meet the insurer's claim function goals.

The proposed philosophy should emphasize providing insureds with fair, prompt, and equitable service, either directly or indirectly, through third-party claim handling. A claim rep should handle a claim in a way that treats all parties involved fairly and equitably and do so in a timely manner. The idea of providing a fair settlement involves paying neither too much nor too little on claims. Combined with the claim department's controlling expenses, this will allow the insurer to achieve profit goals while complying with the contractual promise to pay losses that occur and while building goodwill with customers and the public.


What are the two reserving methods that help avoid stairstepping?

Roundtable and expert system


After verifying coverage and setting reserves, what preparations should the claim rep make before making the initial contact with any of the parties to a claim.

Prepare a list of questions for the insured or claimant and a set of instructions on how the claim will be handled and which actions the insured or claimant will have to complete as part of the claim process.


What are some sources a claim rep can consult with to ensure a knowledgeable evaluation?

• DA
• Other lawyers
• Supervisor
• Coworkers
• People who make up a typical jury
• Damage/Injury evals (computer generated)
• Jury verdict research companies


Why must a claim rep be familiar with bad faith law in states where they handle claims?

• bad faith law is case law AND state law
• Legislation has been introduced to allow claimants the right to sue for unfairly/fraudulently delaying or denying payments both were defeated (California Fair Insurance Reg. Act Prop 30 & 31and Wyoming 1999)


left off on 3-5

left off on 3-5


What determinations does the claim rep make based on the facts of the case?

Cause of loss


What does the claim rep have to check before making a payment?

-the policy (for additional loss payees or mortgages)
-claim documentation for attorneys and lienholders (medical providers)
-the federal asset control master list of potential terrorists and drug traffickers
-state child support or judgment databases


Which two attributes of an insurance contract led to bad faith law?

-insurance contracts involve public interest
-insurance contracts involve a higher standard of conduct due to unequal bargaining power.


Why must claim reps stay informed of bad faith law?

The bases on which bad faith claims can be brought is constantly changing.


Contrast standards got claim reps an lawyers in good faith negotiation.

Claim reps have to make realistic offers and carefully consider all demands. Lawyers have no standards and can make exaggerated demands.


Which one of the following loss reserve methods may use subjective information such as the name of the treating physician in creating the reserve?

A. Loss ratio method
B. Loss analysis method
C. Expert system method
D. Individual case method

C. Expert system method, which is a method of setting reserves with a software application that estimates losses and loss adjustment expenses. While similar to the formula method, it includes more subjective information in creating the reserve.


Claim representatives should be aware of the restrictions imposed by the Fair Credit Reporting Act if they find it necessary to obtain or disclose an insured's financial information during

Choose one answer.

A. A financial audit of a commercial insured's business.
B. A claim investigation.
C. Litigation involving alleged bad faith on the part of the insurer.
D. The claim evaluation process.

B. The Fair Credit Reporting Act is important to claim representatives because they need to be aware of restrictions relating to the insured's privacy.


Juanita is the senior claim officer for Worthy Insurance Company, which uses the claim audit as a performance measure for its claim operations. Claim audits usually evaluate both quantitative and qualitative factors. Which one of the following factors is qualitative for Juanita and her staff?

Choose one answer.

A. Percentage of recovery from subrogation
B. Accurate evaluation of insured’s liability
C. Average claim settlement value by claim type
D. Accuracy and completeness of data entry

B. Accurate evaluation of insured’s liability is a qualitative audit factor.


At year-end, SBC Insurance Company posted the following results:

Incurred losses - $18 million
Loss adjustment expenses - $2 million
Underwriting expenses - $5 million
Written premiums - $26 million
Earned premiums - $24 million

Based upon the company's year-end results, which one of the following represents SBC's loss ratio?

Choose one answer.

A. 83%
B. 75%
C. 96%
D. 104%

A. 83%. LR = (IL + LAE)/ EP x 100%.


Many courts have rejected negligence as a grounds for bad faith, instead using gross misconduct as the standard. All of the following are true, EXCEPT:

Choose one answer.

A. Insurers that are merely negligent in their claim handling face no consequences, regardless of jurisdiction.
B. Bad faith might fall somewhere between simple error and outright fraud.
C. Some courts look for behavior on the part of the insurer which is arbitrary, reckless or indifferent or involved intentional disregard.
D. Courts attempt to determine the insurer's state of mind when establishing gross misconduct.

A. Insurers that are merely negligent in their claim handling face no consequences, regardless of jurisdiction.


any homeowners policies include an appraisal provision that describes a dispute resolution process involving two appraisers and an umpire. Which one of the following statements concerning this appraisal process is true?

Choose one answer.

A. The amount of a loss in dispute is established if both appraisers agree on the amount.
B. Only the insured can demand an appraisal in the event of a disagreement.
C. The appraisal process determines whether coverage applies to a loss.

D. The insurer pays all expenses associated with the appraisal process.

A. The amount of a loss in dispute is established if both appraisers agree on the amount.


Because insurers control how claims are resolved, courts reason that insurers should be responsible for the outcome of their claim handling if they have acted in bad faith. Therefore, courts hold insurers to a higher standard of conduct to

Choose one answer.

A. Encourage insurers to be equitable in all insurance transactions.
B. Encourage insurers to keep rates accurate, fair, and reasonable.
C. Discourage insurers from abusing their position of power.
D. Discourage insurers from deceiving the public in marketing and advertising practices.

C. Insurers create the contract and are therefore in a superior position of knowledge and power. Therefore courts hold insurers to a higher standard of conduct to discourage them from abusing their position of power.


Claim management involves many duties crucial to good-faith claim handling such as consistent supervision, thorough training and

Choose one answer.

A. Expense management.
B. Organizational skills.
C. Customer service soft skills.
D. Manageable caseloads.

D. Manageable caseloads.