Ch 8 Flashcards
(173 cards)
0
Q
Type of ownership where two or more owners have a complete, indivisible interest in a property. If one owner does, ownership is not transferred; it goes to the other owner(s)
A
Joint ownership
1
Q
What is the simplest and most obvious example of interest in property?
A
Ownership
2
Q
Joint tenancy between husband and wife.
A
Tenancy by entirety
3
Q
Type of ownership where two or more owners has a fractional financial interest in the property. (Timeshare)
A
Ownership in common.
4
Q
An interest created by contractual agreement or law where the secured party is usually a creditor.
A
Security interest.
5
Q
How does the policy handle insurable interest?
A
It limits payment on a claim to the extent of the insured’s interest.
6
Q
Why is letting an insurer accumulate more than its insurable interest in the insured property a problem?
A
It would provide an incentive for fraud.
7
Q
Who are the three parties who are generally entitled to make a claim?
A
First named insured, named insured and named insured’s spouse.
8
Q
What are the questions a claim rep must answer as part of claim handling process?
A
1) who has insurable interest and who is a named insured
2) what property is insured? Where is it insured? When is it insured?
3) what are the covered causes of loss?
4) what is the dollar amount of loss?
5) what are the insured’s duties after a loss?
6) what procedures are used to conclude a claim?
9
Q
When determining what property is covered, the claim rep must understand the difference between _______ property and ________ property.
A
Real property and personal property
10
Q
Which three questions help a claim rep determine whether property is real or personal?
A
1) how permanently attached to real property is the fixture? (Furnace is fixture, window a/c is not)
2) is the fixture well adapted to the real property? (Custom window treatments are real property, non custom are not)
3) what was the intent of the owner? (Owner would expect that shelves bolted to the wall would be removed when a tenant moved, but built-ins would not be)
11
Q
Damage to property caused by a covered loss with no intervening cause.
A
Direct loss.
12
Q
What is the most important type of indirect loss?
A
Loss of use of property.
14
Q
What is necessary for an indirect loss to be covered?
A
A direct loss is necessary to tigger loss of use coverage and to determine duration of coverage.
15
Q
A loss which occurs when property can no longer be used for its intended purpose due to destruction, damage or disappearance. It is tangible.
A
Physical loss
16
Q
Intangible loss which includes loss of value not caused by physical damage or destruction. Examples include obsolescence,, loss of market, investment loss, financial fraud.
A
Nonphysical loss
17
Q
Which exclusions can complicate verification of causes of loss?
A
- Gradual causes of loss
- Ordinance or law
- Faulty design, construction, or material
- Intentional acts of the insured
18
Q
How does an adjuster review a claim when gradual causes of loss are involved?
A
Wear and tear, rush, decay, deterioration could cause damage to property. The adjuster has to separate damage caused by these causes from the damage caused by the direct loss.
19
Q
What do ordinances or laws sometimes require after a direct loss?
A
- Destruction of the structure, which could cost more than the cost to rebuild
- Construction plans, methods, or materials that are different from and more expensive than the originals. Policies only usually cover these by endorsement.
20
Q
What is the first step when determining replacement cost?
A
Identify the property.
21
Q
What are proper estimates based upon?
A
- Specifications: (what must be done … type of materials, quantity of materials, repair or replace?
- Materials: quantity of materials is determined by specifications. Price is based on material costs for similar projects.
- Labor (determine by skilled estimators or published “standard” work rates.
- Overhead (contractor’s cost of doing business (permits, office space, insurance)
- Profit
22
Q
If the policy doesn’t cover full replacement cost until after the property has been repaired or replaced, how does the adjuster pay the claim?
A
1) Release ACV settlement and pay balance after repairs/replacement is complete.
2) Parcel out a replacement cost settlement as repair or replacement is gradually accomplished.
23
Q
The reduction in value caused by the physical wear and tear or technological or economic obsolescence of property.
A
Depreciation
24
Q
Replacement Cost minus Depreciaion
A
Actual Cash Value (ACV)
25
A type of depreciation where a fixed percentage of the property's value is deducted for every year of the property's useful life that the owner has enjoyed.
straight-line depreciation
26
What kind of items cannot be valued using ACV because there is no ascertainable figure for replacement cost?
Antiques, old buildings, some property appreciates in value.
27
Some courts have determined actual cash value to mean ____ ________ value. This approach accounts for the possibility that an item is irreplaceable.
fair market
28
Claim representatives should not apply market valuation unless a ___-_______ secondary market exists.
well-functioning
29
Most courts have determined ACV to mean fair market value. Others have required claim reps to consider factors such as physical wear and tear, obsolescence, market value, and other relevant factors. This approach is known as the ____ ____ ____.
Broad evidence rule.
30
A court ruling explicitly requiring that all relevant factors be considered in determining actual cash value
Broad evidence rule
31
What should normally be applied first? Coinsurance penalty or deductible?
Deductible
32
A method of valuing property in which the insurer and the insured agree on the property's value at the time the policy is written and that states the amount in the policy declarations as the amount the insurer will pay in the event of a total loss to the property. Usually covers fine arts and valuable papers.
Agreed amount
33
In the event of a total loss where the property is insured for stated value, the insurer is entitled to receive no more than the least amount of:
1) ACV
2) replacement cost
3) amount of insurance
34
Most claims are paid with money but some claims are settled by _____ or _______ property.
Replacing or repairing. (Good candidates are scheduled jewelry, cameras, guns)
35
List examples of the insured being required to provide prompt notice.
- report claim promptly to insurer.
- report theft loss to police.
- report theft of credit card to bank.
36
How is an insured required to assist with the loss adjustment process?
- inventory damaged and/or undamaged property
- make property available for inspection.
- allow books and records to be inspected.
37
The insured's official version of the loss which is signed and sworn to. All statements are material and, if false, coverage can be voided.
Proof of loss.
38
What information is an insured usually required to provide in a proof of loss?
All info needed to settle a claim:
- time
- place
- cause of loss
- interests in property
- detailed estimates, inventories, bills.
39
How are proof of loss statements treated by the insurer?
- must be responded to within a set number of days.
| - if rejected must send letter explaining why and explaining what insurer needs to do.
40
What is a danger of an insurer waiving a proof of loss?
An insurer might waive valuable rights if they don't spot a nonroutine case soon enough and waive proof of loss.
41
When are examinations under oath (EUO) usually used?
Used after proof of loss is filed when an insurer suspects fraud. Proof of loss commits the insured to a story and the EUO can clarify it.
42
What are the steps in settling a claim?
- determine cause of loss
- determine amount of loss
- document cause and amount of loss
43
a method of valuing property in which the insurer and the insured agree on the property's value at the time the policy is written and that states the amount in the policy declarations as the amount the insurer will pay in the event of a total loss to the property
Agreed amount
44
What are tools an adjuster will use to determine the cause of loss?
- experts (reconstruction)
- SIU
- personally inspecting property
- recorded statement
45
How do insurers handle salvage?
They usually pay full value, take possession of salvage, and sell through a salvage company.
46
What are the two goals of claim reps who handle losses to homes?
1) address the insured's concerns
| 2) enforce policy provisions and protect the insurer's rights.
47
What at the three priorities of a claim rep when handling a dwelling loss?
- help insured keep family safe
- help insured keep home safe and secure and protect contents from further damage.
- explain coverage and the claim process
48
Once the insured's family and property are secure after a dwelling loss, what should a claim rep do?
Thoroughly explain coverage and the claim handling process
Tell insured if they have living expenses coverage or not.
Stress importance of insured's good faith compliance with policy conditions s
49
What does additional living espenae cover?
Increase in living expense to maintain the household's normal standard of living.
50
What is the process of negotiating with contractors?
Contractors should prepare a detailed estimate showing specifications; material costs; hours; labor; additional expenses such as overhead, permits, demolition, and debris removal.
The parties agree on quality and hours and then determine cost of materials and labor.
51
Why does a claim rep usually get involved in hiring a professional cleaning or restoration service in a smoke or water claim?
Quick cleaning can save property, minimize additional living expense, reduce repair cost.
52
a policy provision that imposes smaller limits for certain kinds of property or lines of insurance
Sublimit
53
Why can't claim reps with only residential experience handle commercial structure losses?
Construction principles, methods, materials, and available contractors differ for commercial and residential structures. Architects are sometimes used to help develop estimates.
54
With a commercial structure loss, why can't the claim rep always hire the lowest bidder?
Low bid night be due to lack of expertise or a faulty estimate.
55
Who enters into contracts with contractors to repair damaged property? The claim rep or the insured.
Only the insured. The claim rep might solicit bids to help.
56
How does the value of commercial structures differ from residences?
Supply and demand is mainly determines the value of a commercial structure. Wear-and-tear isn't as much a factor with commercial structures. Commercial structures are more prone to economic and technological obsolescence. (ex. old warehouse may have poor lighting and poor ventilation)
57
Who can help a claim rep determine the rental rates for commercial property?
Realtors.
58
Why is extent of depreciation taken by an insured in its financial records irrelevant?
It is a tax deduction so insureds may over depreciate it for their records.
59
What is a difficulty a commercial insured with a mortgage may run into when their building is destroyed?
The mortgage is due in full upon destruction of the property. Even though the insured may want to rebuild, the mortgageholder may require full payment.
60
What are the three reasons a claim rep should be concerned about contamination and pollution losses?
1) Claim rep's own healthy and safety could be at risk.
2) Coverage for pollution cleanup is extremely limited on most policies. This must be communicated to the insured.
3) The claim rep should have contacts with specialized technical services to help an insured decontaminate a site. Should be careful not to lead insured to believe it will all be covered if that is not the case. (usually cheaper and faster than EPA)
61
Which 3 things does a claim rep have to prove to establish arson?
1) incendiary fire (expert)
2) motive (main focus - determined by SIU)
3) opportunity (SIU)
62
When handling a business income claim, which issues should a claim rep focus on?
- Identify best settlement approach
- Determine business income loss
- Determine the period of restoration
- Determining the extra expense amounts
- Consulting accountants to determine amounts
63
settlements made before property has been repaired. Useful when insured doesn't intend to repair or replace property.
prospective settlements
64
settlements made after property has been repaired and the policyholder has resumed operations
retrospective settlements
65
sum of (1) net profit or loss that would have been earned or incurred if the suspension has not occurred and (2) normal operating expenses, including payroll, that continue during the suspension
Business income
66
Why are disagreements between the insurer and the insured common with retrospective settlements?
Insurance covers only the time in which repairs should be made, not necessarily the amount of time taken to complete the repairs.
67
What are two formulas for business income?
1) revenue - cost of goods sold - discontinued operating expenses. (easier approach)
2) net profit (or loss) + operating expenses that continue
68
the period during which business income loss is covered under the BIC forms, it begins 72 hours after the physical loss occurs and ends when the property is (or should have been) restored to use with reasonable speed (with regard to extra expense coverage, it begins immediately after the physical loss occurs)
Period of restoration
69
How can the time in which repairs should be made (for purposes of BIC or extra expense)?
By consulting with the contractors hired to do the work.
70
Coverage for extra expense can only be settled ______.
Retrospectively
71
A claim rep authorizing expedited construction methods to speed up construction and a retailer leasing a temporary location to maintain sales are examples of this?
Extra expense
72
Which type of claim requires extensive accounting assistance?
Extra expense. Accountants have to determine normal business expenses.
73
Which issues are unique to merchandise claims?
Salvage and salvor services.
74
What are some things to consider when valuating merchandise?
Shop wear
| Depreciation caused by obsolescence
75
How are claims handled when merchandise is covered under a reporting form?
- determine value of inventory as of the date of the last report. (If total loss)
- if under reported, insured cannot recover full amount; they recover did/should times loss amount.
- if failed to submit report when due, payment won't be more than last report.
- if insured doesn't even submit first report, 75% is paid.
76
Demonstrate how negotiation can benefit the insured and insurer when settling merchandise losses.
If insured keeps salvage, they are already set up to sell the merchandise. They can sell it for a higher price than the insurer, who might only be able to sell it for a small percentage of the value.
77
Policies for carriers and bailees typically protect the interests of both the _______ and the _______. A claim rep must usually settle two claims resulting from the same loss: the ________'s and the _______/_______'s.
Owner Carrier/bailee's
Same
78
Who do claim reps usually deal directly with on a Bailee/carrier policy?
The property owner.
79
a document acknowledging receipt of goods from the shipper, given by the carrier which includes terms of contract of carriage for the goods
bill of lading
80
a bill of lading that limits the carrier's liability for cargo loss in return for charging a lower freight rate than would be charged for carrying the cargo subject to full valuation
released bill of lading
81
What are exceptions to common carriers being held liable for damages to an owner's goods?
Acts of god, war, negligence of the shipper, exercise of public authority, inherent vice of the goods.
82
Liability claim reps spend less time evaluating policy _______ and most of their time and effort investigating and evaluating the ________ aspects of liability and damages.
Terms / legal
83
What are the four steps in handling a liability claim?
1) determining coverage (ex. bi or pd caused by certain individuals driving certain vehicles)
2) determining legal liability
3) determining damages
4) negotiating and settling the claim.
84
What must a claim rep do when coverage for a liability claim is doubtful?
Must explain to the insured clearly, in writing, why coverage is doubtful, and what each party must do.
85
What should a claim rep do if part of a liability claim is not covered?
Explain why, referencing policy provisions. Tell insured they will keep handling claim but that insured may have to contribute. Invite insured to contact a private lawyer.
86
What does a claim rep have to do when coverage for an entire liability claim is doubtful?
Explain in writing
Investigate further
Reserve rights
Pay claim or send denial
87
What is an lengthy and expensive way to settle coverage questions in a liability claim which may also complicate defense of the underlying action?
Declaratory judgment.
88
When might a lawsuit seeking injunctive relief instead of money be honored?
Claims for interference of use of property could be a legitimate loss of use claim, which is considered property damage.
89
Which of the following is covered under a liability policy? (With pd and bi)
Breach of contract resulting only in financial harm
Lawsuits alleging financial fraud
Collision with another auto
Collision with auto
90
Are claims for emotional injury only covered?
It depends on the jurisdiction. If they allow tort based claim for emotional injury only then they can make a claim.
91
Why is applying the intentional acts exclusion difficult?
Two questions need to be answered.
1) did the insured intend the result or just to commit the action?
2) can intentional acts be excluded when the claimant also alleges negligence or strict liability?
(Also can insured be liable for acts of an agent or servant?)
92
Why do claim reps have to know the state law defining intentional acts when trying to apply the intentional act exclusion?
In the case of an assault, in some states you need to prove intent to cause the resulting injuries. In others you just have to prove that they intended to commit the assault.
93
If a claimant wants to increase chance of winning a settlement when there is an intentional act, what could he/she do?
Allege negligence or strict liability. When part of the claim is covered and part is not, the insurer has to defend the insured and the insurer may have to settle.
94
What is the dilemma when litigating a claim with an intentional act?
Litigating to deny the claim is not in the best interest of the insurer. The attorney defending the insurer cannot be the same as the attorney litigating to deny the claim.
95
Scenario: insured breaches insurance contract. Insured does work negligently when building a wall. Wall collapses and injures someone. What is covered?
Cost of rebuilding wall is not covered but injuries are.
96
What purposes does prompt contact with a claimant serve?
Preserve evidence, reassure about insurers responsiveness, greatly reduce chance they will hire a lawyer.
97
If a witness is available to testify and they previously gave a statement, what is the only thing it can be used for?
Impeachment.
98
What is the most important aspect of any investigation?
Obtaining all of the relevant evidence.
99
A civil wrong not arising out of breach of contract.
Tort.
100
What does a cause of action in negligence require?
Duty owed to claimant, a breach of that duty (must be proximate cause) that causes harm, and actual bodily injury or damage.
101
If the insured could have ________ ________ an accident, he/she is probably negligent.
Reasonably avoided
102
A cause that, in a natural and continuously sequence unbroken by any new and independent cause, produces an event and without which the event would not have happened.
Proximate cause.
103
What other behaviors besides negligence can result in tort liability?
Intentional torts (assault, trespass, false imprisonment, defamation)
Strict liability (regardless of negligence) (product liability, zoo, fireworks store)
104
How does a claim rep handle criminal liability?
Convicted criminals don't usually cooperate. The claim rep may have to concede liability, but not always coverage. The claim rep will usually wait until criminal proceedings have concluded.
105
a contractual provision that obligates one of the parties to assume the legal liability of another party
Hold harmless agreement
106
A defense to negligence that bars a plaintiff's recovery for harm caused by the defendant's negligence if the plaintiff voluntarily incurred the risk of harm.
Assumption of risk
107
A common-law principle that requires both parties to a loss to share the financial burden of the bodily injury or property damage according to their respective degrees of fault.
Comparative negligence
108
A common-law principle that prevents a person who has been harmed from recovering damages if that person's own negligence contributed in any way to the harm.
Contributory negligence
109
Liability imposed on a party because of that person's relationship to a wrongdoer.
Vicarious liability.
110
What is the most important issue regarding vicarious liability for claim reps?
Scope of employment or agency. If act committed while not at work, not covered.
111
What are two difficult situations when trying to determine the scope of employment?
Employees often make deviations from their employer's business to attend to personal matter.
Employees attempt to conduct the employer's business by prohibited means. (Speeding to next appointment)
112
What are the most useful defenses to liability claims?
```
Comparative negligence
Contributory negligence
Assumption of risk (skiing)
Statute of limitations
Absence of negligence
```
113
What is the difference between pure and modified comparative negligence?
Pure: as long as claimant isn't 100% responsible, he/she may still recover an amount reduced by his/her own negligence.
Modified: 50% and 49% rule. 50% can recover if liability isn't more than the other party. 49% may not recover if 50% or more at-fault.
114
Damages that can be quantified, such as medical bills and list wages.
Special damages
115
Intangible damages such as pain and suffering.
General damages.
116
To be compensated, what do medical expenses have to be?
Related to the loss, necessary, reasonable.
117
What resource does a claim rep have to evaluate necessity and frequency of treatment after the fact?
Review services.
118
Commendable injuries that are difficult to measure, such as physical and mental distress and inconvenience associated with a physical injury.
Pain and suffering.
119
What does consortium traditionally consist of?
Sex, society and services.
120
What is an important difference between first-party and third-party pd claims?
Property owner's own negligence is irrelevant in first-party claims but can be a major factor in settling third-party claims.
121
What is the most valuable activity a claim rep performs for insureds, claimants, insurers, and society and why?
Settling liability claims. If claims went to court the courts would be overwhelmed and insurers would pay more in legal fees and verdict amounts.
122
A claim that implies or involves actual or constructive fraud, a design to mislead or deceive another, or a neglect or refusal to fulfill some good-faith duty or some contractual good-faith obligation.
Bad-faith claim
123
An agreement in settlement of a claim involving specific payments made over a period of time.
Structured settlement
124
A payment made to a claimant following a loss to cover the immediate expenses resulting from that loss. A partial payment to a third-party claimant that is issued before obtaining a signed release.
Advance payment
125
A settlement that involves lump-sum payments made by insurers to settle claims and that does not require a release from the claimant.
Walk-away settlement
126
Provide an example of a bad-faith claim with regard to negotiating a settlement.
When an insurer rejects a settlement within the policy limits and the court rules in excess of policy limits.
127
When are structured settlements appropriate?
When a claimant is likely to experience regular damages into the future, such as loss of income, or when the claim rep thinks the claimant can't manage a lump sum.
128
Why are structured settlements attractive to insurers?
They can offer a larger total settlement at a lower present cost. Insurers can fund the future obligations with annuities purchased from another insurer.
129
Why is the duty to defend important?
Without the insurer's defense, a plaintiff would be in a strong position to coerce settlements from defendants who lack the resources or ability to resist lawsuits.
130
Explain the insurer's right to defend.
The insurer can select the defense lawyer and the insured has to cooperate with the chosen lawyer. The insurer can dictate defense strategy and decide whether to settle or continue defense.
131
What can skid marks tell you about an accident?
Indicate speed. Can disprove a party's statement or establish liability. The place where the marks begin show where the driver first reacted to a hazard.
132
Why are UM claims difficult to defend with respect to liability or on the basis of comparative negligence?
The insured is usually attorney represented. There are no favorable witness because the other party is usually unavailable or uncooperative. If available they often do not make a good witness. If an agreement over settlement exists, the insured can require arbitration.Arbitrators give the insured the benefit of the doubt.
133
What is a major point of contention with UIM coverage?
The definition of an underinsured motor vehicle. Some states have a limits trigger (limits lower than injured party's limits), while other states apply a damages trigger (negligent driver has limits lower than injured party's damages).
134
Ann has UIM with a $50k limit. Randy has a $100k BI limit. Anne is injured and incurred $150k in damages. How does this work with a limits trigger ... and with a damages trigger?
Limits trigger: Randy has a higher limit than ANN so Anne's UIM doesn't apply.
Damages trigger: Anne's damages are higher than Randy's limit so Randy's UIM will apply. (if Ann's damages were only $75k then UIM wouldn't apply because Randy's limit is sufficient)
135
When does stacking of UIM limits occur?
When two or more limits apply to a single accident. It occur when more than one policy (interpolicy) or more than one vehicle on one policy (intrapolicy) covers the loss.
136
A total loss that occurs when the cost to repair damaged property plus its remaining salvage value equals or exceeds the property's pre-loss value
Constructive total loss.
137
What is the bases got legal liability in premises liability claims?
Failure to maintain premises in reasonably safe condition. Determined by negligence theories.
138
How is a premise liability claim investigated?
- witness and claimant statements
- photos of the scene
- examine cleaning or maintenance records
- determine scope of contractors duties, get copies of the contracts, determine what role a contractor might have played in the accident.
139
What are the three common reasons claimants provide for the cause of their accident?
- no idea what caused (no negligence)
- they knew of the causes but failed to observe and avoid them. (Comp neg)
- well aware of and observed the causes but encountered then anyway. (Voluntarily walk across icy sidewalk) (assumed risk, no negligence)
140
What is the primary difference between premise and operations liability?
Premises is unsafe condition, operations is unsafe act.
141
What is the difference between assuming contractual liability and liability due failure to supervise?
Contractual liability is assuming liability for another and failure to supervise is based on contractor's own failure.
142
A written or oral statement in a contract that certain facts are true.
Warranty.
143
An explicit statement about a product by the seller that the buyer or other user may rely on and that provides a remedy in the event the product does not perform as claimed. Advertising material.
Express warranty.
144
Who handles product liability claims?
The manufacturers insurer for products sold in the same condition they left the manufacturer in. If the manufacturer is out of business or cannot be identified, the vendor is responsible.
145
How is liability determined in product liability claims?
Ask if product could have been made safe an still perform intense function. (Except for tools etc.) engineers often have to provide opinions. We're warnings adequate and would they have prevented the accident? Did claimant read instructions? did the claimant use the product properly?
146
What does part 1 of a workers comp policy cover?
Coverage for BI. (Caused or aggravated by conditions of employment)
147
What is part 2 of a worker comp policy?
Employer's liability. (Must prove negligence) covers those not covered by wc law.
148
What does employers liability cover?
Covers employees not subject to wc law.
Covers care and loss of services to spouse and family member of an injured employee.
Covers third party over claims. (Employee sues manufacturer and manufacturer sues the employer)
Cover dual capacity claims (sues employer in capacity other than employer while also asserting a wc claim (ex. Products liability)
149
Why do wc policies have no limit?
Law requires employer to pay all necessary and reasonable medical expenses related to the BI sustained on the job.
150
Why can WC claims be extremely large? (Leading to premiums increasing rapidly)
- no policy limit
- claimant doesn't pay a copay
- wc insurers don't have same bargaining power as health insurers.
- many states have no fee schedule or other control over medical expenses.
151
Managed care plan that contracts with healthcare providers for medical services provided to plan members at discounted fees; (in exchange for referrals) members' choice of healthcare providers is not restricted, but members have a financial incentive to choose contracted providers.
Another definition:
An administrative organization that meets the common needs of healthcare providers and clients and that identifies networks of providers and contracts for their medical services at discounted rates.
PPO
152
How do wc insurers control medical expenses?
PPOs, medical bill audits,utilization review services (determine which treatment is necessary), medical management
153
A medical expense control measure that involves directing and coordinating efforts of healthcare providers to meet patient and insurer needs.
Medical management
154
When is medical management generally used?
Claims with permanent bodily injury requirements payments for the rest of a person's life.
155
What is the benefit of medical management for the claimant?
Allows claimant to live independently rather than in an institution.
156
When can a wc insurer end disability payments?
When claimant agrees or the compensation commission orders payments stopped.
157
How can a wc insurer control disability expenses?
By insisting that the treating physician explain why the claimant cannot perform his or her job.
Work with the employer to modify the job.
Encourage claimants to think in terms of returning to work constantly.
158
What question should a claim rep handling a medical malpractice claim ask?
What could have and should have been done differently at every point?
159
What is the basis of most malpractice lawsuits?
Failure to obtain informed consent.
160
How are damages determined in medical malpractice cases?
What would the claimant's condition have been if proper professional services had been rendered?
161
When the claim rep determines the answer to "what is the dollar amount of the loss?" What issues must they consider?
- valuation basis (ACV, replacement cost, stated amount, agreed value)
- how appropriate amount is calculated
- deductible? And how should it apply?
- should repair/replace option be applied?
- if appraisal clause is invoked? Claim rep must understand the appraisal process
162
How does insure have to assist with the loss adjustment process to meet his or her duties after a loss?
- inventory all damaged and (sometimes) undamaged property
- show property to claim rep
- provide books and records
- cooperate
163
In the conclusion activity for a property claim, what procedure can help minimize the insurer's loss after the payment is made?
Determining salvage value, subrogation rights and related activities.
164
How is the obligation to provide an inventory met by the insurer when written records are unavailable?
Claim rep can review checklist of types of property listing items that are usually in each room.
165
Why does claim rep have more flexibility with scheduled property when settling a claim?
Property is identified precisely. Appraisers can determine it it can be repaired, replaced through secondary market, how much value ha decreased, and whether the insurer can buy replacements as a discount.
166
How does claim handling under a carrier/Bailee policy differ from most property coverage claims?
Two claims are settled; owners and carrier/Bailee's (earned fees, liability for the property's return)
167
What are pre-loss and post-loss activities that can assist insurers when catastrophes occur?
Pre:
- sufficient claim reps in potential disaster area e
- claim offices in these areas should have disaster kits for visiting claim reps (forms, maps, directories, clipboards, calculators)
- administrative departments must be prepared to rent office space and furnishings and prepare living quarters and rental cars.
Post:
- modify claim procedures
- claims paid with less documentation
- reimburse insured for labor
- claims normally needing inspection are handled over phone.
168
What are determinations that need to be made in business income claims?
- settle prospectively or retrospectively
- determine the business income loss; Business Income Report/Worksheet can help
- consider period of restoration and how soon regular operations can resume.
- determine extra expenses insured incurred to avoid or minimize the suspension of business?
169
What are unique problems and elements of premises liability claims?
Injury to the visiting sales reps should be investigated as premises liability claims. Claim reps who handle premises liability claims must establish good rapport with the claimant, both to establish the cause of the accident and to determine comparative negligence.
Usually the claimant asserts that premises weren't maintained in reasonably safe condition. Standard of care is determined by claimant's status on the property. A high level of care is due to business invitees. Claim reps have to get statements from the claimant and all witnesses to trying about the accident or the condition of the accident scene. Photos should be taken if scene hasn't changed.
170
Thomas is a surgeon who routinely performs surgery on patients with nasal problems. People suffering from sinus headaches often consult with him to see if he can provide them with relief from symptoms. Thomas arranges a consultative appointment with each of his patients before scheduling treatment to discuss treatment options, chances of success, and risks associated with surgery. If one of Thomas' patients should experience a negative outcome from surgery, Thomas is likely to be found at fault in a malpractice suit if it is determined that he
A. Failed to provide leading-edge expertise in nasal surgery to the patient.
B. Failed to exercise the standard of care accepted in the profession of nasal surgeon.
C. Failed to provide the patient with full relief from his/her symptoms.
D. Failed to provide an exhaustive written explanation of the risks of treatment and the treatment options.
B. Failed to exercise the standard of care accepted in the profession of nasal surgeon.
171
Why do many professional malpractice insurance policies require the policyholder’s consent to settlement?
A. Many malpractice policies have a high deductible that is the responsibility of the policyholder.
B. The outcome of malpractice claims affects the policyholder’s professional reputation.
C. Many malpractice policies require the policyholder who rejects a proposed settlement to be responsible for any verdict in excess of the proposed settlement.
D. Malpractice claims are litigated by the most sophisticated plaintiff and defense attorneys.
B. The outcome of malpractice claims affects the policyholder’s professional reputation.
172
Which one of the following statements is correct?
Choose one answer.
A. The values that attorneys and adjusters place on liability claims are derived from actual results of claims litigated to conclusion.
B. For most liability claims, resolving the issue in court is relatively fast and inexpensive, and results are reasonably predictable.
C. In liability claims, selection of the defense attorney and the defense strategy rests with the insured defendant.
D. Generally, an insurer need only defend that part of the claimant’s allegations that are covered by the liability policy.
A. The values that attorneys and adjusters place on liability claims are derived from actual results of claims litigated to conclusion.
173
Antonia and Philip have their home insured with ABC Insurance under a standard homeowners policy. During a storm, a lightning strike resulted in a fire in the home's kitchen, and the high winds caused a tree to fall on the roof leaving a large hole. Quite a few shingles were blown off the remainder of the roof. The homeowners report the claim to ABC and make emergency repairs to protect the property from further damage. The claim is assigned to Trevor at ABC. Because the home is uninhabitable, Antonia and Philip incur additional living expenses for meals and lodging while the home is being repaired. In investigating the loss, Trevor determines that the roof tiles are worn and deteriorated and that the entire roof should be replaced. In addition, the wiring in the house in not in compliance with the local ordinance and should be upgraded when any significant repair or renovation is done. Using the framework for coverage analysis and activities in the claim handling process, which one of the following best describes how Trevor will determine the dollar amount of this loss?
Choose one answer.
A. He will include the cost to repair damage caused by fire in the kitchen and the hole in the roof, and will offer to reimburse the cost of emergency repairs and additional living expenses.
B. He will include the cost to repair damage caused by fire in the kitchen and the hole in the roof, and will offer to reimburse the additional living expenses as well as upgrades to the wiring due to local ordinance.
C. He will include the cost to repair damage caused by fire in the kitchen and the hole in the roof, but will not reimburse the emergency repairs or additional living expenses because these expenses are generally not covered.
D. He will include the cost to repair damage caused by fire in the kitchen, to replace the roof on the entire home, and will reimburse the cost of emergency repairs and additional living expenses.
A. He will include the cost to repair damage caused by fire in the kitchen and the hole in the roof, and will offer to reimburse the cost of emergency repairs and additional living expenses.
