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I read it 4 times I still do not understand your post

Contact the adjuster that sent it back and ask them. Odds are they are just repeating what some supervisor told them to write.

JWG

Is it possible they are referring to this?

Denver Urban Renewal Authority | Denver, Colorado | Welcome to Dura

 

I think they are referring to DORA not DURA. DORA is the dept. of regulatory agencies in Colorado. You can acess them by going to www.dora.state.co.us/insurance. I don't know what they mean by adjust it to DORA adjustment standards, but maybe this will help. Adjusters don't have to be licensed in CO.

Colorado Insurance Law, found here: http://www.michie.com/colorado/lpex...1207262520 (linked to the site Benny mentioned; sorry Chuck D. I still don't know how to paste a link correctly)

10-3-1115. Improper denial of claims - prohibited - definitions - severability.

(1) (a) A person engaged in the business of insurance shall not unreasonably delay or deny payment of a claim for benefits owed to or on behalf of any first-party claimant.
(b) For the purposes of this section and section 10-3-1116:
(I) "First-party claimant" means an individual, corporation, association, partnership, or other legal entity asserting an entitlement to benefits owed directly to or on behalf of an insured under an insurance policy. "First-party claimant" includes a public entity that has paid a claim for benefits due to an insurer's unreasonable delay or denial of the claim.
(II) "First-party claimant" does not include:
(A) A nonparticipating provider performing services; or
(B) A person asserting a claim against an insured under a liability policy.
(2) Notwithstanding section 10-3-1113 (3), for the purposes of an action brought pursuant to this section and section 10-3-1116, an insurer's delay or denial was unreasonable if the insurer delayed or denied authorizing payment of a covered benefit without a reasonable basis for that action.
(3) If any provision of this section or its application to any person or circumstance is held illegal, invalid, or unenforceable, no other provisions or applications of this section shall be affected that can be given effect without the illegal, invalid, or unenforceable provision or application, and to this end the provisions of this section are severable.
(4) The general assembly declares that this section is a law regulating insurance.
(5) This section and section 10-3-1116 shall not apply to insurance issued in compliance with the "Workers' Compensation Act of Colorado", articles 40 to 47 of title 8, C.R.S.
(6) This section and section 10-3-1116 shall not apply to title insurance issued pursuant to article 11 of this title or to life insurance issued pursuant to article 7 of this title.
Source: L. 2008: Entire section added, p. 2172, § 5, effective August 5.
Editor's note: This section was contained in a 2008 act that was passed without a safety clause. For further explanation concerning the effective date, see page ix of this volume.

another section:

h) Unfair claim settlement practices: Committing or performing, either in willful violation of this part 11 or with such frequency as to indicate a tendency to engage in a general business practice, any of the following:

(I) Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue; or

(II) Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies; or

(III) Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies; or

(IV) Refusing to pay claims without conducting a reasonable investigation based upon all available information; or

(V) Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed; or

(VI) Not attempting in good faith to effectuate prompt, fair, and equitable settlements of claims in which liability has become reasonably clear; or

(VII) Compelling insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insureds; or

(VIII) Attempting to settle a claim for less than the amount to which a reasonable man would have believed he was entitled by reference to written or printed advertising material accompanying or made part of an application; or

(IX) Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of, the insured; or

(X) Making claims payments to insureds or beneficiaries not accompanied by statement setting forth the coverage under which the payments are being made; or

(XI) Making known to insureds or claimants a policy of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration; or

(XII) Delaying the investigation or payment of claims by requiring an insured or claimant, or the physician of either of them, to submit a preliminary claim report, and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information; or

(XIII) Failing to promptly settle claims, where liability has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage; or

(XIV) Failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement; or

(XV) Raising as a defense or partial offset in the adjustment of a third-party claim the defense of comparative negligence as set forth in section 13-21-111, C.R.S., without conducting a reasonable investigation and developing substantial evidence in support thereof. At such time as the issue is raised under this subparagraph (XV), the insurer shall furnish to the commissioner a written statement setting forth reasons as to why a defense under the comparative negligence doctrine is valid.

(XVI) Excluding medical benefits under health care coverage subject to article 16 of this title to any covered individual based solely on that individual's casual or nonprofessional participation in the following activities: Motorcycling; snowmobiling; off-highway vehicle riding; skiing; or snowboarding; or

(XVII) Failing to adopt and implement reasonable standards for the prompt resolution of medical payment claims.

(i) Failure to maintain complaint handling procedures: Failing of any insurer to maintain a complete record of all the complaints which it has received since the date of its last examination. This record shall indicate the total number of complaints, their classification by line of insurance, the nature of each complaint, the disposition of these complaints, and the time it took to process each complaint. For purposes of this paragraph (i), "complaint" shall mean any written communication primarily expressing a grievance.

(j) Misrepresentation in insurance applications: Making false or fraudulent statements or representations on or relative to any application for an insurance policy, for the purpose of obtaining a fee, commission, money, or other benefit from any person;

(k) Requiring, directly or indirectly, any insured or claimant to submit to any polygraph test concerning any application for or any claim under any policy of insurance;

(l) Violation of or noncompliance with any insurance law in part 6 of article 4 of this title;

(m) Failure to make promptly a full refund or credit of all unearned premiums to the person entitled thereto upon termination of insurance coverage;

(n) Requiring or attempting to require or otherwise induce a health care provider, as defined in section 13-64-403 (12) (a), C.R.S., to utilize arbitration agreements with patients as a condition of providing medical malpractice insurance to such health care provider;

(o) Failure to comply with all the provisions of section 10-3-1104.5 regarding HIV testing;

(p) Violation of or noncompliance with any provision of part 13 of this article;

(q) Increasing the premiums unilaterally or decreasing the coverage benefits on renewal of a policy of insurance, increasing the premium on new policies, or failing to issue an insurance policy to barbers, cosmetologists, cosmeticians, manicurists, barbershops, or beauty salons, as regulated in article 8 of title 12, C.R.S., regardless of the type of risk insured against, based solely on the decision of the general assembly to stop mandatory inspections of the places of business of such insureds;

(r) Advising an employer to arrange for or arranging for an employee or an employee's dependent to apply to a plan developed pursuant to the "Colorado High Risk Health Insurance Act", under part 5 of article 8 of this title, for the purpose of separating such employee or employee's dependent from any group health coverage provided in connection with such employee's employment;

(s) Certifying pursuant to section 10-16-107.2 or issuing, soliciting, or using a policy form, endorsement, or rider that does not comply with statutory mandates. Such solicitation or certification shall be subject to the sanctions described in sections 10-2-704, 10-2-801, 10-2-804, 10-3-1107, 10-3-1108, and 10-3-1109.

(t) Certifying pursuant to section 10-4-419 or issuing, soliciting, or using a claims-made policy form, endorsement, or disclosure form that does not comply with statutory mandates. Such solicitation or certification shall be subject to the sanctions described in sections 10-3-1107, 10-3-1108, and 10-3-1109.

(u) Certifying pursuant to section 10-4-633 or issuing, soliciting, or using an automobile policy form, endorsement, or notice form that does not comply with statutory mandates. Such solicitation or certification shall be subject to the sanctions described in sections 10-3-1107, 10-3-1108, and 10-3-1109.

(v) Failure to comply with all provisions of section 10-16-108.5 concerning fair marketing of basic and standard health benefit plans, and section 10-16-105 concerning guaranteed issue of basic and standard health benefit plans;

(w) Failure to comply with the provisions of section 10-16-201.5 concerning the renewability of individual health benefit plans;

(x) Violation of the provisions of part 8 of article 1 of title 25, C.R.S., concerning patient records;

(y) Violating any provision of the "Consumer Protection Standards Act for the Operation of Managed Care Plans", part 7 of article 16 of this title by those subject to said part 7;

(z) Willfully violating any provision of section 10-16-113.5;

Colorado1221.....I thing you might need a lawyer....

JWG

it's really fairly simple. some of what I copied relates to the agent SELLING the policy; some relates to MEDICAL claims. Focus on the fair claims practices: just do a good job investigating the claim, pay (or recommend payment) of what you owe, don't play games with the insured, don't lie about what's covered, and you should be fine.

I notice that there is no affirmative duty to tell the insured what IS covered or that something that you notice IS covered, but there is a duty not to misrepresent the policy.

Of course regardless of whether you TELL the insured about something if you don't PAY for it it could be bad faith.

usually if you are professional and fair you won't be violating fair claims rules in any state except for the possibility of sending letters late. California has a lot of timelines that have to be followed- 15 days to respond to a claimant, 15 days to begin investigating a claim, etc.

It looks like the Colorado rules just say "reasonable" time to respond.

You can always send a letter to an insured saying that you have received their correspondence and you are reviewing what they are claiming and will let them know what you decide within a week or so, wording to that effect usually satisfies the requirement to communicate.

It's fair to let the insured know what information you are missing.

I went back and re-read your original post. If you "totalled" the roof, it doesn't seem like you would be violating any fair claims rules, so what are they really asking?

If you took an unreasonably long time to decide that it was totalled that could have possibly been bad faith or poor claims handling but that is a moot issue if the customer has been paid.

Maybe there is something in the Colorado guidelines about how much to pay on a damaged roof and they want to follow some kind of standard that is less generous than what you recommended? And ask the insured to send back the money?

I would ask them to send you the "Dura Adjustment Standards" in writing. Even if it's supposed to be "Dora" ask them exactly what they said to you.

This is what they are asking for!!

 

Roof Computation Worksheet - Slope Method - Repair or Replace ?

Insured Name:

Claim #:

Insured Address:

Adjuster

Use the following guide to enter roof computations. The Blue area represents Repair Cost, Yellow represents Replacement Cost

Holding the mouse over each area with the red triangle in the corner show a description. This prints in Landscape format.

Slope

Damaged

Repair Cost

Repair Cost

Squares/

Shingle/Sq

X

/Shingle

X

RDF

X

/Square

X

Slope

=

Repair Cost

# of Shingles

Repair Factors (RDF)

Replacement

Squares/

Replacement

Comparative

OR

1.0 Good Condition 1.5 Fair, 2.0 Poor

Cost/Square

X

Slope

X

Waste %

=

Cost

X

60%

=

Replace Cost

Replace

Front

X

$ 7.50

X

1.5

X

$ -

X

=

$ -

#

X

X

10%

=

$ -

X

60%

=

$ -

Rear

X

$ 7.50

X

1.5

X

$ -

X

=

$ -

#

$ -

X

X

10%

=

$ -

X

60%

=

$ -

Right

X

$ 7.50

X

1.5

X

$ -

X

=

$ -

#

$ -

X

X

10%

=

$ -

X

60%

=

$ -

Left

X

$ 7.50

X

1.5

X

$ -

X

=

$ -

#

$ -

X

X

10%

=

$ -

X

60%

=

$ -

X

X

X

$ -

X

=

$ -

#

$ -

X

X

=

$ -

X

=

$ -

X

X

X

$ -

X

=

$ -

#

$ -

X

X

=

$ -

X

=

$ -

Somebody spent a lot of time to develop this. Apparently roofs in Colorado are always gable; never hip. That should make your measuring easier. I wouldn't use a spreadsheet like this in California because it would be bad faith on any hip roof, especially since I know better.

Or maybe the example you posted is locked, and the real version allows you to make changes. And the people who want you to use it are OK with you acting as an adjuster and making changes for accuracy.

Wagenmaster, just to be clear, thanks for posting that, nothing against you. But if this is how they require adjusters to estimate roofs, in my opinion they are not allowing adjusters to be adjusters. On closer inspection maybe the 10% is for waste factor on individual shingle repairs only. But what is the 60%? The inverse of a 40% depreciation? If so, every roof has 40% depreciation? And the $7.50 per shingle repair cost is for all types of shingles? Or just 30 yr comp? Is this just a worksheet to help adjusters calculate whether it makes sense to do a lot of repairs instead of replacement? Well, if the adjuster writes for extensive spot repairs will that come with a warranty from the carrier like the large red company does? And what if this worksheet indicates that a particular roof would cost $9000.00 to repair but $10,000. to replace the whole slope. Will the carrier pay $9000.00 or go ahead and pay $10,000 because it is within a certain percentage? What if no roofer is willing to repair it for $9000.00? (because of the liability). Are you allowed to point out that a particular roof is unrepairable (due to age?) even though many shingles are undamaged? I have a lot of questions about what this spreadsheet is supposed to do and how it fits into the overall claims adjustment process.

I would like somebody to explain it who has actually used it.

Leland - not a problem. It was that this thread had taken off in all directions and I was just trying to get it back on course. I got the worksheet about 10 years ago when I worked for Safeco and if you had a wood roof w/ damage you were supposed to do the worksheet to determine repair vs replacement. It is a worksheet only. The pricing and % factors are just left over from the last time I used it. It is from Haag Eng. Composition/Wood Roofs Damage Assesment seminar handouts. (page 47-48)   Not too sure if the example uploaded or not. I'll have to work on that

 

Mike

if you'll send me your e-mail address I'll send you the X cell worksheet and directions they want you to use

wagenmaster

Hey Wagenmaster,

I ran across your post while I was trying to find the DURA Excel spreadsheet. Do you still have the Excel version? If so, would you mind e-mailing it to me? I really need a copy, quickly. 

 

Thanks!

Brett