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Last Post 06/17/2013 4:40 PM by  greenmachine
Red Flags / Uncooperative Insureds
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greenmachine
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04/30/2013 10:43 AM
    Sandy was my first flood event, and what an event it has been!

    I have an insured whose behavior has been questionable, to put it mildly.  Sandy was his fourth loss that I am aware of.  

    The PA, who also worked the insured's Irene claim, sent me an extraordinarily over-inflated estimate that included a large amount of items 

    that were paid for after Irene, but not replaced.  Of course, I excluded those items from my own estimate, even though they didn't volunteer 

    any of that information.  It was a matter of comparing old photos with new ones, where possible, although the insured had thrown out the 

    damaged items.  
    Boy, he sure fought hard for that new boiler/water heater combo, until I showed him side-by-side photos.  Note to insureds:  don't leave 

    questionable items on your property, even if covered by a tarp.On top of this, the prior estimate that was filed showed either bogus serial 

    and model numbers or simply "illegible".  

    A good example of what I was dealing with:  

    Prior claim submitted by an IA declared a Ruud boiler:  S/N 6665666 Model: FFFAKEMN
    Estimate sent to me by the PA declared a Ruud boiler:  S/N 6665666 Model: FFFAKEMN 
    Boiler tucked away under a tarp showed a Weil-Mclain S/N 123456 Model: ACTUALMN
    A comparison of prior photos and my photos showed the boiler to be one and the same.  

    So, now this insured wants to file a supplement.  He wants an item covered that I never saw, even though he has a receipt that he owned this 

    item.  He is either unable or unwilling to provide me with photos that show damage to said item occurred, and he is complaining that I've 

    asked for proof of damage.  

    Question:  how do you seasoned adjusters deal with people like this?  In your reports, do you note these questionable actions, or just keep 

    it quiet?  I feel pressure from above to keep it quiet, for fear of cracking open Pandora's Box, but I'm also outraged by the insured's, the 

    PA's, and the previous IA's behavior.

    Thanks for reading this far, and I appreciate any advice and guidance you might offer.

    -Fletch

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    johnclark719@yahoo.com
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    05/05/2013 6:16 PM

    Fletch,

    I will take the bait and give you my take. First of all you are the Adjuster that this will fall back on when reviewed and people will have opinions, just like you seem to indicate of the prior I/A.

    It is your claim and as an adjuster you have to give the facts with what you can back up and based on what is ethical, you know that class, (Ethics), you have to take to keep your adjuster license in Texas. If the facts are as you indicate then that is what you must report if you want to keep working as a Flood Adjuster, or a Wind Adjuster for that matter. The file reviewers are professionals also so if you fabricate a report and it is picked up on then you may not be adjusting for them again. That is why your report it as you see it with the information and facts that you have, along with your recommendations. It is then the responsibility of the Insurance Company to make the final decision on the next step. I would not want to make an unethical decision that may keep me from working. Let the Insurance Company tell you the next step after you have given them all the information with the supporting facts of your recommendation.

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    CatAdjusterX
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    05/06/2013 1:38 AM
    Posted By Fletch on 30 Apr 2013 10:43 AM
    Sandy was my first flood event, and what an event it has been!

    I have an insured whose behavior has been questionable, to put it mildly.  Sandy was his fourth loss that I am aware of.  

    The PA, who also worked the insured's Irene claim, sent me an extraordinarily over-inflated estimate that included a large amount of items 

    that were paid for after Irene, but not replaced.  Of course, I excluded those items from my own estimate, even though they didn't volunteer 

    any of that information.  It was a matter of comparing old photos with new ones, where possible, although the insured had thrown out the 

    damaged items.  
    Boy, he sure fought hard for that new boiler/water heater combo, until I showed him side-by-side photos.  Note to insureds:  don't leave 

    questionable items on your property, even if covered by a tarp.On top of this, the prior estimate that was filed showed either bogus serial 

    and model numbers or simply "illegible".  

    A good example of what I was dealing with:  

    Prior claim submitted by an IA declared a Ruud boiler:  S/N 6665666 Model: FFFAKEMN
    Estimate sent to me by the PA declared a Ruud boiler:  S/N 6665666 Model: FFFAKEMN 
    Boiler tucked away under a tarp showed a Weil-Mclain S/N 123456 Model: ACTUALMN
    A comparison of prior photos and my photos showed the boiler to be one and the same.  

    So, now this insured wants to file a supplement.  He wants an item covered that I never saw, even though he has a receipt that he owned this 

    item.  He is either unable or unwilling to provide me with photos that show damage to said item occurred, and he is complaining that I've 

    asked for proof of damage.  

    Question:  how do you seasoned adjusters deal with people like this?  In your reports, do you note these questionable actions, or just keep 

    it quiet?  I feel pressure from above to keep it quiet, for fear of cracking open Pandora's Box, but I'm also outraged by the insured's, the 

    PA's, and the previous IA's behavior.

    Thanks for reading this far, and I appreciate any advice and guidance you might offer.

    -Fletch

    .....................................................................................

    Fletch, this is something that you must be very cautious with regard to how and when and depending upon the circumstances........IF you should pursue further.

    It seems pretty suspicious nevertheless, your final paragraph concerns me. You state "pressure from above" to keep this quiet. So are you stating that your claims manager/file examiner is pressuring you to stay quiet about suspicious circumstances?

    Secondly you state that you are outraged at the insured/PA. OK that is at least understandable (given the circumstances) but what do you mean about being outraged with the previous IA? Are you talking about the adjuster for this insured's Irene claim?

    With that, please clarify.

    On its face (and based SOLELY upon your information), it appears that there is something nefarious going on. This much I can tell you with certainty, do NOT voice your thoughts to the insured and/or the PA.

    In regard to your reports, with NFIP claims there is a significant paper trail, do NOT discuss those thoughts on paper. I say that because should you be wrong, oh hell, even if you are right but cannot prove it, you are putting yourself/the IA firm to which you are contracted with and last but not least the National Flood Insurance Program in a precarious position.

    My advice would be (under normal circumstances) to stay mum with your suspicions to the insured and/or PA but write down your suspicions (NOT on any NFIP docs) and then voice those thoughts to your claims manager or file examiner and let them take it from there until such a time that the SIU decides if a fraudulent act has occurred. They will contact you.

    Let me be clear, even if your claims manager/file examiner wants you to stay quiet (please clarify what you mean about "pressure"), should this come out later, any monies paid by the NFIP could be your responsibility (if they knew that you knew about this, yet did not say anything)

    If it doesn't make sense to you why your superior(s) want you to stay quiet, you may consider going over their head(s)

    I say as much because you have everything to lose (your NFIP license/certification as well as probably all state licenses you hold. If big enough, there could be a felony charge and some jail time) and little to gain by staying quiet.

    UNDERSTAND THAT THIS IS WORST CASE SCENARIO AND AGAIN BASED SOLELY UPON YOUR INFORMATION 

    The above information is for informational purposes ONLY and is NOT legal advice. What you do is up to you.

    If you don't feel comfortable posting additional information on a public site, you could contact me at:

    Robby@avCATrecovery.com



    "A good leader leads..... ..... but a great leader is followed !!" CatAdjusterX@gmail.com
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    tonyd46
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    05/08/2013 9:50 AM
    In response to your question please point out the the insured's pa quoting the NFIP dwelling policy section J page 12 of 19 REQUIREMENTS IN CASE OF LOSS NUMBER 6. you MUST COOPERATE WITH THE ADJUSTER OR REPRESENATIVE IN THE INVESTIGATION OF THE CLAIM AND SECTION k OUR OPTIONS AFTER A LOSS SECTION1 PARAGRAPH A. show US THE DAMAGED PROPERTY AS WELL AS SECTION 2. NUMBER E.
    IT IS THE DUTY OF THE INSURED OR HIS PA TO PROVE THEIR LOSS. IF THEY DON'T PROVE IT WE DON'T PAY FOR IT
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    K ung Fu tzu
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    05/10/2013 10:11 AM

    Fletch,

    This is an easy answer. Just defuse the situation quickly by advising the PA you can't do anything else until he submits a duly executed proof of loss. He knows if he submits a claim for duplicate damage, he'll be committing fraud. The proof can be rejected if necessary. Either way, this will bring your claim to a quick conclusion.

    Many new adjusters such as yourself don't realize that it's the policyholder that must produce the proof of loss, but are sometimes taught that the carrier 'supplies' the completed form for the insured to complete. The latter is only done as a courtesy to advance the claim process.

    This is a good way to stay on top of the claim process and keep your emotions (outraged) out of the equations.  Remember, it's not personal, it's just business.


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    ChuckDeaton
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    05/10/2013 12:51 PM
    Where Proof of Loss is concerned it is necessary to differentiate between the requirements of the National Flood Insurance Policy, which is a Federal regulation and an insurance policy written by an admitted carrier.

    In many states, if Proof of Loss is required on a specific form, that form must be provided to the insured with a stated period after the loss.
    "Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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    Tex Walker
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    05/21/2013 10:43 AM
    Whats with all the letters in different colors, bold and italicized ? I think we ALL get the point and are able to read, reminds me of poorly constructed ransom letter :)
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    ChuckDeaton
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    05/21/2013 7:05 PM
    Be careful, Tex, you'll be receiving threatening emails and texts that make you pass pictures out to local security.
    "Prattling on and on about being an ass with experience doesn't make someone experienced. It just makes you an ass." Rod Buvens, Pilot grunt
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    CatAdjusterX
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    05/22/2013 12:56 AM

    Posted By Tex Walker on 21 May 2013 10:43 AM
    Whats with all the letters in different colors, bold and italicized ? I think we ALL get the point and are able to read, reminds me of poorly constructed ransom letter :)

    ........................................................

    Tex, the only point of this "post" is to stir the pot and nothing more. Take your little comments and  flame war somewhere else. 

    "A good leader leads..... ..... but a great leader is followed !!" CatAdjusterX@gmail.com
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    CatAdjusterX
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    05/22/2013 12:58 AM

    Posted By ChuckDeaton on 21 May 2013 07:05 PM
    Be careful, Tex, you'll be receiving threatening emails and texts that make you pass pictures out to local security.

    ...............

     



    "A good leader leads..... ..... but a great leader is followed !!" CatAdjusterX@gmail.com
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    pondman
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    05/22/2013 8:23 AM

    Robby,

    No disrespect here, but professionally speaking, you should take your own advice.  When I do "crap" like that, my other half calls me "kettle"..............meaning the pot calling the kettle black.

    With everything we have going on, did you really need to even respond? Let it go., turn the other cheek. I know with all that is happening we can "all" spend our time more wisely in more productive and positive manner.

    Good Day....and may all of you stay safe.

    Give them what they want, when they want it, and how they want it !
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    65Daily
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    05/22/2013 3:37 PM
    Nice, the senile old geezer pulls out his needle and his immature hot-head buddy cranks on his stupid bandanna. Anyone taking bets?

    You've heard it before: "Don't fight with pigs. In the end, both of you get dirty, but the pig likes it"; apparently, neither of you have even showered yet.

    This thread title needs to be revised, "Red Flags / Uncooperative Morons".
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    CatAdjusterX
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    05/24/2013 5:47 AM
    Posted By Pondman on 22 May 2013 08:23 AM

    Robby,

    No disrespect here, but professionally speaking, you should take your own advice.  When I do "crap" like that, my other half calls me "kettle"..............meaning the pot calling the kettle black.

    With everything we have going on, did you really need to even respond? Let it go., turn the other cheek. I know with all that is happening we can "all" spend our time more wisely in more productive and positive manner.

    Good Day....and may all of you stay safe.

    .......................................

    Agreed

    "A good leader leads..... ..... but a great leader is followed !!" CatAdjusterX@gmail.com
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    okclarryd
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    05/24/2013 11:50 PM
    This kinda reminds me of an old Marine adage:

    To err is human...........to forgive is totally out of the question.

    Happy Trails
    Larry D Hardin
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    greenmachine
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    06/17/2013 4:40 PM

    Thanks for your replies.  I didn't realize this thread had gotten so many replies.

     "So are you stating that your claims manager/file examiner is pressuring you to stay quiet about suspicious circumstances?"

    No.  "Pressure" was not the best word for me to use.  These types of issues, when they have come up, seem to be very low priority, though.  Pay what is owed, deny the rest.  Next claim.

     

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