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CCarr
Canada
1200 Posts |
 Posted - 01/26/2003 : 14:09:07
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It has been said in a number of forum posts that, "some state laws require you to explain to the insured, contents of the policy when doing a claim".
I am not familiar with those laws or requirements.
Please advise:
(a) What State(s)?
(b) What law(s)?
(c) The nature of the requirement(s)?
(d) Explain to what extent?
Chuck Deaton responded to this post in an unrelated thread, by suggesting it was an interesting thought. He added, "I have always 'thought' that the Arkansas Fair Claims Practices Act requires an explanation of coverage to the policyholder.
I responded in that unrelated thread by saying, "okay lets start with Arkansas - with regards to my four part question, can you give me a sentence or two from their FCPA that addresses these questions, or a web link for review? |
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JimF
USA
1014 Posts |
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JimF
USA
1014 Posts |
Posted - 01/26/2003 : 21:37:48
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Below are 3 excerpts from the Arkansas Department of Insurance "Unfair Claims Settlement Practices" which at least convey the spirit of what Chuck Deaton made reference to concerning an adjuster's obligation to inform insureds on policy coverages:
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State of Arkansas
Department of Insurance
Unfair Claims Settlement Practices
§ 9. Standards for prompt, fair and equitable settlements applicable to insurers
(d) Every insurer, upon receiving notification of a claim, shall promptly provide necessary claim forms, instructions, and reasonable assistance to claimants so that first party claimants can comply with the policy conditions and the insurer's reasonable requirements.
(g) No insurer or its agents and representatives shall fail to disclose fully to first party claimants all pertinent benefits, coverages or other provisions of an insurance policy or contract under which a claim is presented.
(h) No agent shall conceal from first party claimants benefits, coverages or other provisions of any insurance policy or insurance contract when such benefits, coverages or other provisions are pertinent to a claim.
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CCarr
Canada
1200 Posts |
Posted - 01/26/2003 : 22:04:17
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Well Jim you beat me to it, I just got back from the AR DOI Insurance Law web site, and have read what you refer to.
Agreed, they do convey the spirit of what Chuck was suggesting, and I think that 'spirit' is how all claims should be handled.
However, I don't think Rule & Regulation 43, and your specific excerpts from it, say that "you are required to explain to the insured, contents of their policy when doing a claim".
But it does answer all four parts of my question, and I take from it my own interpretation, specifically for parts (c&d) of the question. |
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Newt
USA
657 Posts |
Posted - 01/27/2003 : 06:39:21
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Disclosure could take many forms, writing, word of mouth or even a video tape.IMHO
I assumed incorrectly, that to explain something means word of mouth, and the word disclose can have many ways to inform the client. I can see the error of my thinking.
I don't always understand what I hear.
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Edited by - Newt on 01/27/2003 06:51:06 |
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JimF
USA
1014 Posts |
Posted - 01/27/2003 : 14:36:27
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Having read the comments since posting the excerpts from the Arkansas Unfair Claims Settlement Practices, I must say that I am somewhat at a loss to understand any dichotomy here.
Let's go back for a moment and review just one of the excerpts which I posted as follows:
(g) No insurer or its agents and representatives shall fail to disclose fully to first party claimants all pertinent benefits, coverages or other provisions of an insurance policy or contract under which a claim is presented.
Now I would argue that adjusters are 'representatives' of an 'insurer', thus their conduct is applicable under this Act.
Second, while the language is not specifically and precisely exact with what Clayton said he was looking for, it seemed to me close enough, that I suggested it followed the 'spirit' of what Chuck Deaton suggested.
It does seem to me that if an insurer's representative (that's US folks) is required to DISCLOSE FULLY to first party (Insureds) claimants ALL benefits, COVERAGES and other provisions of an insurance policy or contract under which a claim is presented, then each and every adjuster handling a claim within the State of Arkansas is required by Arkansas Law to KNOW insurance policies fully and be able to explain ANY PORTION of that policy specific to different types of claims for ANY given first party insured filing and reporting a claim in Arkansas.
If we think about it, the negatives of the statement "NO...SHALL FAIL...to FULLY DISCLOSE', restated in a positive way, means that Arkansas adjusters are REQUIRED by LAW to explain those portions of a policy specifically applicable to a specific loss and/or loss type.
I just don't see how anyone can read any less or any more into such language, and personally, I have always felt it was every adjuster's personal obligation and responsibility to possess both that ability and willingness before ever adjusting their very first claim.
But then again, to my way of thinking, one peril 'adjusters' and 'roof thumpers' are not and never will be "Adjusters" by any measurable standard of accepted adjusting professionalism.
So what the heck do I know. |
Edited by - JimF on 01/27/2003 17:39:17 |
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Joe Aymond
USA
8 Posts |
Posted - 01/27/2003 : 16:16:26
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So, let me jump in here. Anyone take this that the insurer or representatives to be the writing agent in an agency. The guy that first writes the coverage, or do you take this to be adjuster only. I don't want any bashing, but as an agent for over 20 yrs it is our responsibility to advise our customer what his policy does and doesn't cover when we write the app. Just thought I'd pass that along as I am selling my agency 3-1-03 anyway.
Joe |
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Newt
USA
657 Posts |
Posted - 01/27/2003 : 17:03:08
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Congratulations Joe, You are selling a business that owns you. I just sold mine a few years ago, it wasn't Insurance but just about as involved with about 3400 clients. Anyhow, starting with retirement,you will wonder how you had time to make a living. Maybe you have tried it before, I have three times and each time I fail miserably at being retired. Good luck......
(Edited by Admin) |
Edited by - Newt on 01/27/2003 17:28:14 |
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Tom Toll
USA
154 Posts |
Posted - 01/27/2003 : 23:57:13
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Well, as far as education progression goes, this one sucks. I have no intention of getting into a word battle with anyone. Simply stated it goes like this.
You are a licensed adjuster. One of of requirements is to understand policy and provisions. When you get a claim, you are, by law and ethically required to infrom an insured as to what coverages he is entitled to on that particular claim. Elaboration of policy content is not necessary. We must understand that the majority of policy owners have no idea what is in the policy, and what may or may not be covered. If you want to be a good adjuster, you will take the time and explain what coverage they have on that claim. Makes for getting the insured on your side too, and satisfies all the Insurance Deparments little rules. You should want to help the insured remove stress by knowing what you are doing.
So, lets make all this simple, tell the insured what coverage is available on that particular claim. Don't use big elevator words, speak in plain english so they will understand you. When they understand you, they help you. |
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KileAnderson
USA
875 Posts |
Posted - 01/28/2003 : 00:27:47
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So how's this?
Your roof is damaged. It needs to be replaced. It is covered under your howmeowners insurance. It will cost $5000 to replace your roof and you have a $1000 deductible so I am issuing a payment for $4000. Here is your itemized estimate. Do you have any questions? No? Ok then, it was nice meeting you, I'm sorry it was under these circumstances. Have a nice day.
Does that cover it? |
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Newt
USA
657 Posts |
Posted - 01/28/2003 : 07:32:01
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Tom and Kile, Take the grain and throw the straw out, I gotcha, and that is what I thought, just didn't know how to put it. I think I could get that message over to the client. It is a simple matter of getting the insured on your side by telling him what to expect out of his/her coverage. Also if there is any time limits, make sure to mention that so they won,t get a surprise later on.
You are going to ask some questions anyway, so I would try to wrap up those loose end at the same time. Then you are free to do what ever you got to do in order to get a claim written up.
I figure the adjuster has to control the claims process in order to be effecient, without seeming to be unconcerned with the problems of the client. If you demonstrate your concern, you will get a bond. Thats not adjusting, thats life in the real world. |
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ChuckDeaton
USA
373 Posts |
Posted - 01/28/2003 : 07:40:01
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I handle residential and commercial claims in a variety of sizes and caused by a variety of perils. Water, fire and wind being common perils. I find that most insureds treat these events as what they are, personal disasters. Disbelief, dismay, anger, disruption and depression, along with other emotions, are part and parcel of every residential claim. I very nearly always explain that a Fair Claims Practice Act exists, that I am licensed and that my license is at the discretion of the Insurance commissioner. I always explain that attorneys are available and that we will work with an attorney if the insured hires one. I always attempt an explaination of the coverage available. The truth is that almost no one understands their insurance policy. I always explain my equipment, how the estimate will be written and the time line. I explain subrogation and Cause and Origin experts and the use of engineers.
As adjusters we need to keep in mind the fact that a large residential claim has the potential to grow beyond the immediate loss and into a catastrophe that will ruin the insured's life while at the same time following the policy wording and the company line. |
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JimF
USA
1014 Posts |
Posted - 01/28/2003 : 07:59:54
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Any adjuster who has done fairly extensive storm 'clean-up' will tell you that around a fourth to a third of files which 'reopen' are reopened because the adjuster failed to explain applicable coverages and/or the insurance claims settlement process.
Having done more reinspections than I ever care to remember, I have never stopped learning how horribly bad some 'adjusters' have either failed to discuss coverage with an insured at all, telling the insured they should call their agent if they have policy questions (which really means the adjuster has no idea or knowledge of policy) or else, the adjuster provides incorrect and incomplete information, which either creates an estoppel situation and/or makes it quite difficult for the clean-up crews to reclose.
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Edited by - JimF on 01/28/2003 08:01:16 |
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Newt
USA
657 Posts |
Posted - 01/28/2003 : 10:17:26
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Jim& Chuck, Experiences is where its at, these posts are very informatiive. Sometime I get explainations that are very good yet being thick of skull, I have trouble remembering or just dont understand.
I was hesitant in using "Chuck" in my justification, and not being real sure I understood you.
What I remembered was for the most part was correct, so you must have done a good job.
In reality I wouldn't do it any other way. It protects the empolyer and consumer in two ways. First, if the Agent explains it and misses the mark, then the adjuster reinforces it.
These are complex contracts, or at least several pages. I have problems in every claim we discuss here on the forum and have to study, not just read each one. Unless the client is gifted beyond any thing I have seen, its only fair that we should inform them of coverage, claim specifics and any deadlines they should be aware of.
I think that is a good law and if complied with would certainly make the cleanup as Jim talked about, a lot easier.
I might add that things are getting a bit easier for me as far as policys go, I can find specifics a lot quicker. I know for what and why I am looking. Before I had to go from cover to cover and still not be sure what applied. Now it a case of going over the whole thing and knowing most of the time just what applies. I will get better, I hope. Thanks |
Edited by - Newt on 01/28/2003 10:21:41 |
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CatDaddy
USA
310 Posts |
Posted - 01/28/2003 : 10:25:27
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JimF is right on the money.
Spending a little more time to thoroughly explain to an insured the claims process will save you lots of questions on the back side.
This explanation, or "your rap" as I like to call it, will eventually become a reflex. It is mainly the same information everytime concerning the claim's process and what you are there to do, you will just have to tailor any policy information to the type of claim it is.
"Good morning Mr./Mrs. Insured. I am Newt with Ajax Insurance Company. We spoke on the phone yesterday."
"Yes, good morning"
"Thanks for meeting with me this morning. I know you are in a hurry to get back to work so I will try to make this go as quickly as possible."
"Thanks, I told my boss I would be gone a couple of hours."
"That should be plenty of time. Tell me again a little about what type damage you have noticed as result of the storm."
"Well, I saw here the hail beat my metal building up pretty bad. I just put that thing is last month. It tore my screens up on that side of the house too. And that piece of metal that runs along the edge of the house all the way around, the fa'sher I think you call it. Its got dings in it too on that one side. And I want you to check the roof"
"Have you noticed any interior damage thats a result of the storm?"
"No, inside's ok."
"Well Mr. Insured, let me tell you what I am going to be doing today. I am going to check the entire outside of the house and the outbuildings for any type of damaged related to the storm. I'll take a look at your fence and I'll also check for any damage to personal property items that might be out there, like lawn furniture, gas grills, lawnmowers, etc. I will look at all those areas that you just told me about but I just wanted you to know that I'll actually be looking at it all."
"Oh, well that's good."
"It will probably take me 20 or 30 minutes to get a complete scope of the damage. After that, I'm going to be in my vehicle for a about 20 minutes or so writing my estimate. When I get it finished, I'll knock on the door and we'll go over it together."
"Ok, well I'll be inside. Just knock when your finished."
"Thanks."
(imagine Jeopardy music)
Knock...knock.
"Ok Mr. Insured. I think I got it all. Let me go over it with you."
"Have a seat."
"I got up on the roof. It has some pretty extensive hail damage. I know you told me it was only 3 years old but with this size hail, its a total loss. You have a 20 year, 3 tab roof. Here is where I removed the
first layer, then put the new shingles down. Your turbines will have to be replaced, there they are. You had a few damaged vent caps and the pipe jack flashings will also have to be replaced. Here is where I allowed for them. When you start comparing my estimate with any roofers estimates, you can refer to this subtotal under the roofing section so you'll be comparing apples to apples. If you get an estimate that differs from mine, please contact me before any work begins so that the roofer and I can work out the differences. Once he and I agree on a replacement cost, the work can begin."
"Ok."
"The front, rear, and right elevations looked fine. I did not find any damage on them and thats consistant with the direction the storm came from and how hard the wind was blowing."
"Yeah, I was standing in the yard, when the sky just started turning green, then the wind starting coming out of the east. I really thought we were gonna get hit by a tornado. The lights went off and we went and sat in the hall until the noise stopped. It sounded like a train!"
"Well, thank goodness it was just alot of wind and some hail. We'll get you back in shape."
"Good."
"On the left side, the screens will have to be replaced, here they are. I also noticed that the window on the left was broken. It looks recent. Probably a piece of flying debris. I allowed to reglaze it. The frame of the window was not damaged. A glass shop can probably do both of these repairs for you. Just pick you out one and have them by. Again, if their estimate differs from mine, please give me a call."
"Ok."
"And that metal along the edge of the roof, the "fascia", is damaged on that side. I included the cost to repair it here. Your house being only 3 years old, matching this material should be no problem. You'll need to contact a siding contractor for that repair. He will be able to find what you need."
"Your metal building took a beating too. You said it was new last month. Where did you get it?"
"My wife brought it home. I am not sure."
"Did she tell you what it cost?"
"Yeah, but I cant remember right off. $400 maybe, for the kit. I put the damn thing together. I've never seen so many screws! I wont do that again."
"Well, the price list I have has a general price for buildings of this type; kit buildings that you can get at Sears, Lowes, or Home Depot. I included it here. It includes materials and labor. We'll use it today and after you talk to your wife and track down where it came from and what it actually cost, we'll make an adjustment then if we have too. I also included a couple hours general labor for removing and resetting the contents of the building. They'd be impossible to work around."
"Ok, thanks."
"Well Mr. Insured, that was everything I found and I gave it a good look. Here is the total of all the repairs with tax. Less your deductible, that leaves this about payable. And here is a check for that amount."
"You are giving me a check today?"
"Yep..ready for the bank. My name and phone number are listed here on the estimate. That phone number is my voicemail and it pages me after you leave your message. If you discover any other damage you think might be related to the storm, feel free to give me a call. This type of wind and hail damage is covered under your policy. I'll call you back and if I can take care of it over the phone, I will. If not, we'll meet here. I also expect to hear from you when you start receiving your repair estimates so I'm sure we'll be talking again soon."
"Thanks Newt."
"You're welcome. Talk to you soon."
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JimF
USA
1014 Posts |
Posted - 01/28/2003 : 10:42:12
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CatDaddy, your comment to the Insured: Tell me again a little about what type damage you have noticed as result of the storm is my all time favorite opening question to any insured. In fact, it is THE ONE question I try to instill in every new adjuster to ask.
First of all, it shows that you want to HEAR the insured which is vital so that an insured feels he/she is being heard.
Secondly, it is an open ended question which will generally elicit information which you might not readily observe otherwise.
It also prevents the adjuster from telling the insured what happened during the storm, which I have seen adjusters do at times, with generally disasterous results in terms of creating trust and win-win communications with insureds.
Thanks for sharing that one vital question which will serve every adjuster well if they will use it as part of their rap as you call it.
I always ask my insureds if they will walk with me around for a general overview of the risk BEFORE I ever start writing a scope/estimate. Again, it makes the insured feel that you care what they think and you make them feel part of the process. Only after doing that, do I then go back and start writing the scope of damages I have seen. This method, I think, also makes it more unlikely for an insured to feel later that something was missed, thus possibly saving you one less return phone call to make.
Oh and one more thing; it's a brave new world of technological advances out there in our year 2003, so by all means, put your personal email address on your business card and on the estimate as well, and advise your insureds they can email you any contractor estimates or contents lists if they have internet capability. You'll find that a growing number of American families do, and it is faster, easier, and more reliable than the mail and will let you close your files quicker which means you get paid sooner! |
Edited by - JimF on 01/28/2003 10:49:50 |
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Some State laws require you to explain coverage
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