Claims Commandments One Through Fifteen on Video Now Available
Claims Commandment XIII — Though Shall Educate Yourself Continuously
Insurance and the law of insurance is continuously changing. As regular readers of Zalma on Insurance are aware new cases on insurance issues come from the courts daily. Facts and practices that are clear and unambiguous today will be ambiguous or wrongful tomorrow. Acts that are considered bad faith today will be considered to be good faith tomorrow.
The key to becoming a professional claims handler is education and information.
To be a professional claims handler it is essential that you understand the covenant of good faith and fair dealing, the basis of insurance, how insurance works, and a high level of skill in the profession.
Claims Commandment XIV — Thou Shall Adjust
The claims handler has been called an “adjuster” for centuries because he or she is capable of adjusting to different situations. In modern practice and adjuster is:
The person knowledgeable in insurance retained by an insurer for the purpose of assisting the insured in proving a loss to the insurer. A person who expresses to the insured the fidelity and good faith of the insurer.
The adjuster is also a person who, “for any consideration whatsoever, engages in business or accepts employment to furnish, or agrees to make, or makes, any investigation for the purpose of obtaining, information in the course of adjusting or otherwise participating in the disposal of, any claim under or in connection with a proof of loss or engages in soliciting insurance adjustment business.” [California Insurance Code § 14022.]
It is the obligation of the adjuster to determine the amount of loss, the cause of the loss, and the final settlement in cash value after all factors have been considered.
To do the task the adjuster must be flexible and ready to work within the confines of the contract of insurance, the covenant of good faith and fair dealing, and simple good manners to work as a partner with the insured or claimant to resolve the claim to the satisfaction of both. If a claim is properly adjusted litigation between insurers and insureds and claimants will diminish and in many cases disappear.
Claims Commandment XV — Thou Shall Not Be Cruel
Insurers pay to the satisfaction of their insureds and claimants approximately 95% of all claims presented. However, there will always be claims made on policies that do not provide coverage.
Advising an insured or claimant that there is no coverage on an insurance policy always falls upon the shoulders of an insurance adjuster. How the adjuster fulfills the task of advising a person that he is on his own and can expect nothing from the insurer can cause, or avoid, a lawsuit from the insured.
It is essential that the adjuster deal with the claim denial in pleasant, empathetic and kind fashion. The adjuster should never be brusk and cruel. The adjuster should never take joy in denying a claim although it is the adjuster’s obligation to comply with the terms and conditions of the policy.
Be kind. Be considerate. Be clear, concise, and advise the person whose claim must be denied, why his claim must be denied. That means the adjuster must provide the insured with the results of the adjuster’s investigation that reveals all of the facts relied upon, how they apply to the specific wording of the policy, and how the facts and the policy wording are interpreted by the courts of the place where the claim occurred. If possible the denial should be written and detailed and presented in person to the insured or claimant so that the adjuster is available to answer any questions raised by the denial.
No insurance policy covers every potential claim. Some casualties are either uninsurable or not insured.