| Author |
 Topic  |
|
ShermaninCO
USA
40 Posts |
 Posted - 02/15/2003 : 09:36:27
|
| In my humble opinion, definitely. But then again I to am missing a few rungs on the ladder. |
Bill Sherman
|
 |
|
|
CCarr
Canada
1200 Posts |
Posted - 02/15/2003 : 15:39:16
|
Newt, most if not all of the additional questions you raise about this scenario, are covered in some detail in other threads specifically related to the issues of your concern; two that come to mind are the 'Non Waiver' thread and the 'Fire Scene' thread.
However, I think that aside from the policy interpretation exercise, that you should not dwell on the other aspects of this claim too much. This is not a claim that would likely come the way of a new person to claims, at least not in their first active 12 months. Don't take it as a criticism, just an observation, that your good and consistent efforts should stay focused on what you may encounter in your early months after you press the 'go' button.
This claim scenario would come to a carrier via an FNOL, with the loss stated in one of two general ways; and this is unfortunately not uncommon. First, the quite generic description, "fire destroyed detached garage", or even less info than that. Second reporting description 'style' on an FNOL is more detailed, "fire destroyed apartment in the converted detached garage".
If the loss came with the first generic description, the carrier is still going to assign it to an adjuster (staff or IA) who is an 'intermediate adjuster' (i.e. 2 to 3, or 3 to 5 years claims experience - depending on the carrier's interpretation of that) who has at least a year of active fire experience.
That generic description on the FNOL, will not 'trigger' the 'concerns' of the adjuster from comparing the loss statement to the coverage noted on the FNOL. That is the unfortunate part of what I was saying before. That adjuster will walk into a much different situation and hopefully within 5 minutes of listening and looking, will recognize that what existed is not as per the policy. That is when the adjuster should get the Non Waiver, then next determine via the carrier what the relationship is to what exists versus what was insured.
The adjuster assigned to the loss with the FNOL saying, "fire destroyed apartment in converted detached garage", should deal with the obvious conflict of that statenment on the FNOL to the coverage stated on the FNOL; before he communicates in any way with the insured. Then, determining that the FNOL loss statement is a 'change' from the current policy, that adjuster should get a Non Waiver basically immediately after introducing himself to the insured; then proceed with a proper investigation. The examples I have given here, both relate to the first scenario I posted about.
Taking the lane that the claim was assigned to an IA, it would be rare that the assignment is on a 'fee schedule' (loss value) basis. Even in the remote chance it was (but it just is not logical), or that it was assigned via one of those 'flat fee' type IA assignments, there are 'triggers' in those arrangements between carriers and vendors, to revert the assignment to T&E; when as in this example, an important element of the claims process will take more time and would be unfair to both parties to be kept as a flat or fee schedule assignment. |
|
|
|
JimF
USA
1014 Posts |
Posted - 02/15/2003 : 20:38:17
|
Clayton, while I generally agree with what you have posted, and especially your comments about the FNOL ('first notice of loss' or 'Accord' or 'Accord form' or 'loss notice' for those who aren't familiar with the terms).
But I have seen claims such as this slip through the cracks into the hands of a newer adjuster, though rarely.
I do think that Newt and Bill still deserve your thoughts in how you would document this file and as well, how you would report it. No doubt this is a 'captioned report ' file rather than a short form report and you may want to comment on that too.
Despite the fact that Newt and Bill are newer adjusters, they did ask a legitimate question, and they deserve the answer, even if they aren't likely to see and handle such a claim for some time down the road.
I don't mean this as a criticism but I am guessing that in addressing the situation, you just overlooked their questions. I am passing it along back to you as you are the 'fire pro' here on CADO! |
Edited by - JimF on 02/15/2003 20:42:41 |
|
|
|
JimF
USA
1014 Posts |
Posted - 02/15/2003 : 20:39:33
|
| Removed By Author As Duplicate Of Prior Post. |
Edited by - JimF on 02/15/2003 20:44:14 |
|
|
|
CCarr
Canada
1200 Posts |
Posted - 02/16/2003 : 06:37:22
|
We have taken 'Inside's' thread and pretty well stretched it to its limits, n'est pas?
I lost a lot of time trying figure out how to take a doc in 'Word' and import it here, with a 'presentation' layout; but the 'cut & paste' just brings it here without the 'presentation' format. Unfortunate and frustrating, another day I'll seek guidance on that.
If this claim did 'slip through the cracks' into the hands of a new adjuster, or an adjuster with no experience in fire claims; that adjuster should immediately advise their supervisor and confront the situation. The reasons for all that were addressed in another thread, in days gone by. The 'slip through' does happen rarely, but the latter logical referral happens more rarely.
Yes, I would certainly think that this would be a full reporting captioned file. I use the following format, unless I am breaking the report into two segments, due to issues of privilege and / or defense counsel involvement. I am not going to make up a mythical step by step, sentence by sentence report narrative, but I will summarize what I think should and should not be in each section, and try and relate it to the first scenario I responded to in this thread.
Date: - of the report
Claim Number: - carrier & IA, if applicable
Named Insured: - as provided in the FNOL, plus any comment or explanation, if findings reveal otherwise. If the 'findings' have a possible affect on the adjustment, do not talk about it here, just point it out and refer to details found in the 'adjustment' portion of the report for applicability.
Location of Insured Risk: - exact comments as per 'named insured' section
Date & Time of Loss: - as per your findings
Agent of Record: - exact comments as per 'named insured' section.
Enclosures: - just list them, no comments. Purpose here is to create a list of 'documentation' acquired or created, so you as the adjuster or anyone reviewing can see just what was obtained that may play a part in the resolution. In this scenario (again the first one re 'change' and no coverage), the list could go something like this;
1. policy declaration page
2. policy application
3. certificate of title
4. standard report form from Fire Department
5. signed statement from named insured
6. signed statement from tenant (Miss. Mary Sister)
7. signed statement of Mr. A. Bucky (neighbour of insured)
8. permit issued by city for conversion of garage
9. invoices from insured for garage conversion costs
10. diagram of detached converted garage
11. photographic presentation
>(a) garage (pre loss) provided by insured
>(b) converted garage (pre loss) provided by insured
>(c) fire loss photos (individually captioned)
12. newspaper article relative to loss
13. location finder map of risk location
14. estimate of damages (prepared by adjuster)
15. estimate of damage (provided by insured contractor)
16. signed Non Waiver agreement
Assignment of Claim:
> First Advise: - when "I" was assigned (date & time). "I" if I am staff, is when claim came into office. "I" if I am an IA, is when vendor received claim.
> First Contact: - this is 'you', when did you first speak (whether by phone or in person) with named insured, date & time
> First Inspection: - this is 'you', when did you first arrive at loss location, date & time.
- if there is no close continuity in these three entries, explain it.
Insurance: - detail it out according to only what was given to you.
PP1234567 HO3 (0491) Homeowner policy
Coverage A - $200,000., all risk
Coverage B - $20,000., all risk
Coverage C - $140,000., named perils
Endorsements - none stated
Deductible $500.
Current term June 15/02 - June 15/03, we note this is a renewal term.
- the above is just a list. Then, if stated coverage is an issue in the claim, detail the 'issues' here and now in narrative and logical format.
eg. - policy indicates single family o/o dwelling
- other structure was a detached garage
- detached garage converted to a rental apartment
- this converted garage occupied as living space, rented to ins'd sister
- we believe due to the following interpretation of the policy in regards to the use & occupancy at the time of the loss that .... (as per my post on this scenario).
- conclude with something like, "Further application of this 'change' with regards to the loss is found in the 'adjustment' section of our report".
- what you are doing is simply pointing out a 'problem' in this specific area, detailing it, and noting it is dealt with later.
Risk Description: - describe what is there at the time of the loss, with sufficient detail on affected or applicable portions.
- single family dwelling, named insured only occupant, with no other uses noted
- dwelling is frame, 2 storey, with unfinished basement, foundation is 44x24'
- dwelling was built in 1985
- insured has owned and occupied dwelling since 1986
- (next paragraph) converted detached garage sits on the premises, 60' detached to the rear of the dwelling
- garage was built at same time as the dwelling
- frame construction (vinyl sided) with steel color panel roof covering
- 36x24' on grade slab
- in 2002, insured converted garage to an apartment, with 1 Bdrm, one 3pc bath, and an open living / dining area with a small kitchen
- all the furnishings and appliances in the apartment were purchased in 2002 by the insured
- further details concerning the converted garage are found in the 'adjustment' section of our report
- there are no other structures on the premises
Ownership / Legal Interest: - we did a title search which disclosed the following
- who the property is registered to
- any mortgages a/o leins
- if nothing is relevant here to the adjustment, just state the data. If something is relevant to the adjustment, address it, but again refer to the 'adjustment' section for applicability
Cause of Loss: - relate data in a logical combination from relevant data obtained, i.e. sis statement, fire department data, your investigation
- bring it all together in logical format to create and confirm clear picture of all steps taken to confirm this was an accidental cooking fire (see this chapter in the "Fire Scene" thread). Bring in relevant items to this 'cause' section from the 'enclosures' list which will all build and support the 'fire' and 'type' of fire, and how it happened and why; think and talk in terms of NFPA 921 (see chapter in "Fire Scene" thread). All to lead to a conclusive statement to end this segment, along the lines as follows; "we are satisfied that this was an accidental hostile fire caused by the negligence of the tenant occupant".
Subrogation: - something along the lines as follows; "we are satisfied the tenant occupying the apartment in the converted detached garage, who was present and alone in that structure at the time of the loss, is negligent for all damages that occured. This tenant, Miss. Mary Sister, was cooking fried chicken on the stove in a 12" cast iron frying pan that contained a quantity of corn oil. This detail is provided in the signed statement she provided, and also indicates she left the stove unattended while cooking to answer the phone; and the grease ignited causing the fire. (another paragraph) We do not feel there is any contributory negligence, by any other party. It has been confirmed, as noted in both the insured and tenant statements, that the insured had supplied and installed a new and adequate fire extinguisher in a proper location in the apartment, that the tenant did not use. (another paragraph) The tenant is identified as follows ...., plus give her background, occupation, and anything else known about her and any 'asset' information. (another paragraph) We suggest that if any indemnity is provided for this fire loss, that demand then be made to the tenant, which we confirm has no insurance.
- kind of a multi step process, identify the negligence, and who is responsible and why, address contributory negligence - what, why and who, make overall conclusion on negligence, provide as much detail as possible on negligent parties.
Quantum of Loss: - this area is just quantum, nothing else, just a specific area to address damages. I tend to start with something along the lines of the following when confronted with this type of scenario; "without regard to coverage, if any, and after a Non Waiver was obtained and a copy provided to the insured, we then took the required steps to estimate the potential loss as follows;
Coverage A - no damage to dwelling
Coverage B - an estimate attached, talk about it, relate it to the estimate insured obtained
Coverage C - no damage to contents of the dwelling
Coverage D - (part #2) Fair Rental Value - say why you are in this section of coverage .... and go on; "there was no lease but we are satisfied from reviewing the insured's bank statements that the insured received $300 per month for rent. Reconstruction period will likely be 2 months, prolonging to 3 months, due to winter conditions. Therefore, the exposure here is $600. to $900.
Additional Coverages - #10 Landlord Furnishings - explain briefly why you are in this section of coverage, speak of the estimate for this section, bringing in the $2500 limit if applicable
Adjustment of Loss: - explain what you have done, in logical order what were the steps you took and why, as applicable. Bring together all aspects and problems encountered and your interpretation of them. This is where you bring together other areas where you said 'refer to adjustment section'. In this scenario the main issue is the 'change' in the risk and its affect on coverage as noted in my earlier post on this scenario.
Recommendations: - what do you want the carrier to do? You may have seven recs or just one. "We recommend that all elements of this loss be denied, based on the information provided. We recommend a blank Proof of Loss be sent to the insured with the denial".
Things to do: - what do you have yet to do on this file? Could be 16 things or none. "We have no remaining steps to complete with regards to our involvement in this matter. If you have any further instructions, please advise".
Forecast of Closing: - depending on any 'things to do'. If so, create a time line and state it, the object here is to illustrate and explain a probable closing date, if not; "If you concur with our findings and recommendations, this file will close in the current month".
Yours truly
Clayton Carr
the person who doesn't want to be referred to as 'the pro' anything on CADO |
Edited by - CCarr on 02/16/2003 08:30:19 |
|
|
|
Newt
USA
657 Posts |
Posted - 02/16/2003 : 07:22:20
|
| I know I may not see a claim like this for some time, however I am trying to cover as much as I can. I will probably never work floods. I am now on my second trip through the NFIP manual. Same with Inland marine, I have been through it three times. I am not trying to jump the traces, I just want to broaden my view. I hope to take the AIC course later and any thing I learn now will help,I hope. |
|
|
|
Newt
USA
657 Posts |
Posted - 02/16/2003 : 07:44:50
|
I knew about the non-waiver of rights and ask the question instead of giving the answer in hopes it would be given in conjunction with the walk through. Any time there is non compliance, fraud, expired policy or misinformation given by the client, we would get a non- waiver agreement signed.
Since it is an important issue, I thought a little repetition wouldn't hurt. |
|
|
|
JimF
USA
1014 Posts |
Posted - 02/16/2003 : 09:09:43
|
Clayton, your post walking us through how to 'caption report' this fire loss just goes to show why I and many recognize you as 'the go-to pro' on fire claim and advanced insurance practices. Captioned reporting especially, is really not addressed at length in the textbooks, and you and Jim Lakes do them better than anyone I know. Perhaps you would consider starting a thread here on CADO and instruct us all in how to do them properly and concisely?
Newt, while I do think it is admirable that you are truly hungry for knowledge, and I also think every adjuster should be aware of and know when and how to use the Reservation of Rights Letter, Non-Waiver Agreements, and subrogation potential, I do not think it likely that you will see all that many situations requiring these the first year or so as you walk down the 'cat' road (assuming claims are assigned based on experience).
Further down the cat road you may, but even for most experienced adjusters, ROR's, NW's and subro are generally seen as a rarity rather than a rule. If you were starting out working day to day claims, your chances of encountering situations requiring these tools from the adjuster's toolbox, would no doubt increase.
The bottom line of what I am saying is be aware of these tools and when and how to use them, and then don't dwell on them to the point of worrying that you are going to see them on every other or every third claim. When the situation arises where they are needed, the need generally will pop up in such a way, that you can't or won't miss it.
|
Edited by - JimF on 02/16/2003 09:12:01 |
|
|
|
CCarr
Canada
1200 Posts |
Posted - 02/16/2003 : 14:03:22
|
| No, thank you, I considered your question to me, and I will pass on that request. |
|
|
|
Newt
USA
657 Posts |
Posted - 02/16/2003 : 15:40:16
|
No Problem, I can look it up,and figure a proceedure from Clayton's response.
I am interested in proceedure anyhow, maybe Inside Man has some input, if not ,its not that important to me. So I figure I have enough to go with.
I thought the subject was for new people and didn't intend my questions to create a problem.
I am OK with not responding to certain questions, if I know which ones I need to stay away from.
The advice given was recieved with respect, I will try to stay in my box:>) |
Edited by - Newt on 02/16/2003 15:57:25 |
|
|
|
Topic |
|
|
|
Pop Quiz: APS -- Is it covered?
Forum Locked
