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C39: Fraud Prevention and Awareness > Study 6: Claims > Flashcards

Flashcards in Study 6: Claims Deck (18)
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The Adjusters Role: Define Adjuster (1) , Independent adjuster (1), and difference between staff adjusters and independent adjusters. (2)

Adjuster - Investigate, determine policy coverage, negotiate, and settle claims

Independent Adjuster - One who adjusts losses on behalf of insurance companies but is not employed by any one insurance company.

-The main difference between the two is that independent adjusters have a lower authority limit to settle cases, and they require approval from a claims supervisor.

-Independent adjusters also need to be licensed, staff adjusters do not.


How are claims usually reported? (4)

-Claims are usually reported to a broker or agent, or to the insurer directly.

-Coverage will be confirmed, as well as details of the claim, and any questionable claims should be referred to the most appropriate claims person for handling.

-The insurers internal adjuster determines the level of investigation, and what experts to use if any at all.

-Certain Companies have Special Investigation Units (SIU's) to handle or to consult on questionable claims.

*Look at counterfeit goods examples pg 126


Claims investigation: Why should large scale natural disasters worry insurers when it comes to fraud? (2)

-These disasters create opportunities for fraudsters to go to work. (Ex: Hurricane Sandy, where vehicles were flooded, and written off, which allowed fraudsters to take advantage and title wash the vehicle, which is when the history of the salvaged vehicle is hidden)

-Auto adjusters must complete a thorough investigation if they become suspicious. They must get full details of history of the vehicle, check authenticity of ownership, as well as examine any losses the vehicle may have suffered.


Claims investigation: Why is it important to have the right adjuster manage a certain claim? (3)

-It optimizes claims handling.

-Established adjusters have connections to professionals in their respected areas, and they have more experience and expertise.

-Attitude is an important element to consider when choosing an adjuster. They must be objective and demonstrate utmost good faith during claims process.


Claims investigation: Discuss some of the key aspects than can help an adjuster during the investigation of suspicious claims. (3)

-Non waiver Agreement - When the possibility of a policy violation or exclusion arises, A non waiver agreement permits the adjuster to maintain contact with the insured throughout the investigation without fear of creating estoppel.

-Reservation of rights letter - Should the insured refuse to sign the agreement, a reservation of rights letter should be sent instead.

-Proof of loss - proof of loss form is required to be provided to an insured by the insurer when a loss happens. This form lets the insured document the incident including details of the loss. These documents
are given to the insured on a without prejudice position, which makes giving the form to the insured not an admission of coverage.


Interviewing Claimants: How may claimant interviews be conducted? (1) and what type of interviews do adjusters conduct? (2)

-May be conducted in person, or on the phone, either formally or informally.

-Adjusters conduct investigative interviews, which is they gather info related to a claim. They do not interrogate.

-Interrogation is an investigative interview where the known facts are matched to a suspect for the purpose of obtaining a confession.


What are the parts of a model interview system? (6) (Table 6.1)

-Plan - Prepare for interview, examine all docs and evidence, formulate questions, make checklists, and do research on the claim.

-Listen - listen to all info that claimant is providing, do not interrupt and let them finish telling their story.

-Remain calm - its never appropriate to get upset at your witness or claimant.

-Ask one question at a time and make notes as you interview - Do not overwhelm the other party, ask questions one at a time and wait for answers.

-Evaluate Body Language - Note the way your witness or claimant is reacting physically. Are the uncomfortable, anxious?

-Ask for an explanation - Ask for clarification when needed.


Formulating Questions: How should interview questions be asked/formulated? (8)

1. Be flexible and think on your feet while asking questions.

2. Be alert to new information.

3. Ask direct questions and clarify ambiguities.

4. Refer to a checklist to make sure you are getting your pre interview questions answered but do not be afraid to go off on tangents to elicit more information.

5. Ask questions to provide a true picture of what happened.

6. Go with your gut feeling.

7. Examine every detail, especially the little ones.

8. Watch the body language.


Statements: Why are statements from insureds an important part of a claims investigation? (4)

-They are a valuable and permanent record of an individuals recollection of an incident while its still fresh in their mind.
-Most claims require a formal statement in writing from the insured.
-Its best to take statements soon after the event as possible, as the longer you wait, the less the insured will recall.
-If a claim is fraudulent, a statement might provide clues to the motive behind the fraud, or point to policy violations.


Why is polygraph testing not used often in the investigation of claims? (2) and what are the several stages of the test? (3)

-It is a controversial topic. Researchers believe that polygraphs can be deceptive, and there may be a "false positive" finding, which is a truthful person may be judged to be lying.

-The polygraph test does not determine if someone is lying, it is the polygraph examiner who analyzes the results and gives their opinion.

-In a polygraph test, an instrument is used to collect physiological data from the subject. The stages of the test are:
--pre test interview
--collection of data
--analysis of data


Expert Witnesses: What should you consider when choosing an expert? (5)

When hiring an expert for a specialized service, ensure you are choosing the expert who is:
1. Properly qualified
2. Reputable
3. Has stable operations
4. Will not bring criticism upon an insurer
5. Continuously train and upgrade in their field


What are the different type of experts who can help with claims investigations? (17) (Know a few for exam)

1. Origin and cause experts
2. Appraisers
3. Engineers
4. Accident Reconstruction Specialists
5. Investigators
6. Surveillance Specialists
7. Photographers
8. Doctors
9. Forensic Accountants
10. Lawyers
11. Computer technicians
12. Forensic Pathologists
13. Employment Consultants
14. Forensic Economists
15. Forensic Video Analysis
16. Forensic Experimentation Experts
17. Any other expert of specific knowledge pertaining to a type of cause


Define Forensic Expert(1)

Someone connected to a court of law, and can be hired by insured or insurer to appear in court as a witness. (Has knowledge of legal process/principles)


What questions might be asked to ensure that a useful analysis had occurred related to the reports submitted by experts? (4)

-Was proper testing carried out?
-How soon after the loss was the scene of accident inspected?
-Was evidence properly handled?
-What effort was made to determine whether there were any changes to the scene since the loss?


How can social media play a major role in the investigations of claims? (5)

-Is one of the newest tools in the fight against insurance fraud.

-Allows adjusters to spy on their claimant without them knowing.

-Sites like Twitter, Facebook, etc allows an adjuster to access pictures and timeline posts of what the insured is doing.

-Social medial allows you to get to know your claimant and their likes, which gives you an insight into the character and habits of the insured.

-When investigating a fraud ring, social media can be used to connect the dots between people from the fraud ring.


How are photographs and videos an important part of a claims investigation? (3)

-Used to remind people of what the area looked like, and they tend to add weight to any physical evidence available.

-They provide a useful record that no physical damage existed in an area.

-Its inexpensive, and can validate existence of any property destroyed.


Claim Denials: What is the time frame for paying out claims as set in the policy conditions? (1) and what can insurers do if they pay out a claim, and later discover it was fraudulent? (1)

-Payment must be made within 60 days of the submission of the proof of loss.

-Insurers can apply to have claimants reimburse insurance money that was paid out. (If fraud was from service providers, actions should be taken against offending party)


Court Testimony: What are some points to consider for an adjuster who must appear in court? (8)

1. Make and Keep Detailed notes.
2. Review your notes just prior to testifying.
3. Speak slowly and clearly.
4. Listen carefully to each question.
5. Take your time to formulate your response.
6. Ask for clarity when needed.
7. Answer the question being asked. Be concise and keep your answers short.
8. Do not allow anyone to intimidate you, and don't be concerned about classifying evidence. Let the court sort out whats admissible or not.