| 12/17/2009 12:52 AM |
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Well, can't say I run into those often, but it looks like I did today. It's one of the wind damage claims. I went up on the roof and after looking around and chatting with the contractor I started to think that a couple of things looked odd. First, there were missing tabs on front and back slopes, BUT they were all laying NEATLY exactly underneath from where they were missing in the gutter. Second thing that looked suspicious was that on the steep part of the roof there was no damage. All damage was on the easily accessible parts. How would you handle this claim? I mean, obviously, there are a few paths here. One, I can report it to carrier's SIU, which has certain ramification, and I could just buy the roof, and give the guy benefit of the doubt. What would you suggest? |
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| 12/17/2009 1:40 AM |
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I have run into several of these. I would call the carrier and tell them your concerns and let them tell you what they want done. Unfortunatley, there is not much that can be done. Eventually, they will end up buying the roof. Odds are the inside adjuster secretly just wants you to pay for it. All reporting suspicians really will do is create a lot more work for you and the poor inside adjuster who is working for peanuts anyway. But if you are like me, you do the right thing and report it.
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Ray Hall Senior Member Posts:2443  
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| 12/17/2009 10:17 AM |
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There are certain ramifications, like I said. First, the insured gets hurt by this. I mean, if they investigate and find that this one had been caused by contractor, who pays the insured, then? Intentional act are excluded as you know. And second, all I have is this weird fact that broken tabs lay in order, nothing more. I am thinking of just buying this roof.
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| 12/17/2009 10:18 AM |
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And, yes, for you record, carrier doesn't care or know about things like that.
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| 12/17/2009 11:14 AM |
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There is no way to prove it. They can pay an engineer 3 grand for his opinion but he is just going to guess. He doesn't know either. And all of it doesn't matter in the long run if the insured keeps fighting they will get a new roof. It's sad but that is the way it is.
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Jud G. Advanced Member Posts:509
| 12/17/2009 1:16 PM |
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I would contact the carrier to advise and air your suspicions verbally.
In the report, I would indicate that the cause of the missing shingles looks like it 'may' be from something else other than wind, but you are not able to speculate or determine precisely what this cause was.
I would submit your estimate for the repairs and indicate that the estimate is not a recommendation for payment, but a reflection of the type of repairs needed. Suggest that additional investigation may be necessary to determine the precise cause. Let the carrier call you back to inquire as to what type of expert may be needed (engineer or SIU) or they will proceed on their own to secure the expert. |
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Ray HallSenior Member Posts:2443
| 12/17/2009 1:22 PM |
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I disagree with all the answers, except mine. If the contractor knocked on the door and the insured did not call him out to inspect for wind damage, this is a biggie. You could pay the claim for the cost of repairs, why is a few tabs missing a total looss. This would be under the EC perils V&MM -MM, then sue the contractor. Make sure who broke the shingles off EUO both insured and contractor. BUT get Co. approval first. This what real adjusters do. Nothing you have recommended is unfair or unlawful. If both the insured and contractor are involved, both of them will make a deal and roll over on the other.
You need a lot more facts about weather direction, other houses around this house etc. Do not accuse, just say your inspection of the roof is not consistant with other roofs you have inspected for wind/hail damage. GET COMPANY APPROVAL, but do some more investigation on damage in the area for this event, age of roof etc. Prior claims. Its not your job to keep cases that need to be investigated further from being correctly worked.They will pay you for your time and expense, turn it over. |
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| 12/17/2009 1:56 PM |
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You can not make the contractor sit for a EUO as he is not in privity as it relates to the contract of insured.
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MedulusModerator  Veteran Member Posts:786
| 12/17/2009 4:56 PM |
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1. Call and alert the inside adjuster to alert the carrier to a possible OTH/OTW (other than hail/other than wind) claim.
2. Write up the estimate and for repair or replacement, as may be appropriate, with language about how this estimate is for information purposes only. It is not a determination of coverage or promise of payment. It must be approved by an employee of XYZ Insurance.
3. Write up exactly what you saw in the narrative part of the report.
4. Hand in the file with your invoice. The decision is the carrier's to make, not yours. Whether the inside adjuster is lazy or what their desire or motivation may be is not your concern. Steve Ebner CPCU AIC AMIM
"With great power comes great responsibility." (Stanley Martin Lieber, Amazing Fantasy # 15 August 1962)
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Ray HallSenior Member Posts:2443
| 12/17/2009 5:01 PM |
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Alan if he has a contingency contract to do the work for the amount allowed by the insurance company does this drag him the back door? Best advise is given by Medulus follow it. |
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| 12/17/2009 6:49 PM |
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Great, but from the responses I see above (other than Ray's) is an indicitment of the "who cares, punch is an estimate and slap a fat invoice on it so I can scoot to the next one" mentality of the IA scene.
1.) Weather conditions on or about the DOL. Use www.noaa.gov to capture all info. Smart enough and you can get the daily & monthly results (wind speed & direction).
2.) Examine, while you're up on the roof what the other dwelling roofs conditions are in the area. Don't just limit the inspection to the roof you are on!
3.) The estimate or contract. Hmmm, date of the document v, the DOL and date of report?
4.) Interview of the insured. What! Yes, you need to speak to the insured (aka - policyholder) and inquire when he how & discovered this purported "loss". Was he contacted by the roofer or solicitor? Knew him before. Saw him working on nearby homes?
Just trying to get the juices flowing between the organ between dem falppers on da side of your head!
The duties of an adjuster be it a independent adjuster, carrier field or staff examiner is to gather the facts and present them in a clear and non-prejudiced way.
Just gathering the basics I layed about above will allow a carrir to either assign a roofing expert/engineer to take it to another level. It is not the IA to recommend an EUO be conducted until there is expert opinion to suggest some type of intentional loss or fraud is present.
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| 12/17/2009 8:01 PM |
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This is a great example of my rant about file reviewers. So far, we have at least 5 different opinions. So all you have to do as an adjuster turning this file in is write to replace the roof, don't write to replace the roof, call the carrier, don't call the carrier and write an estimate, do nothing more until you get instructions from the carrier, and do a lot more work before contacting the carrier.
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| 12/17/2009 10:30 PM |
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Yeah, ya put ten adjusters in an unlocked room and all will have a different viewpoint on how to get up and leave.
Nothing new. That's why deferring to the chain of command who is paying the fee bill is always the better path. Or to put it another way, when picking your fights, always try to pick a fight you know you can win.
Ol' Ghost
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LelandAdvanced Member Posts:741
| 12/18/2009 2:32 PM |
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I have had similar cases where the insurance company agreed to send out a professional roof inspector who determined some shingles were "manually removed" (by hand, not wind).
It is very common (at least in my experience) to use 3rd party experts on daily claims where issues are in dispute.
And relying on independent 3rd party opinions is a better defense against potential bad faith accusations.
And never accuse someone of fraud if you can avoid it. There are diplomatic ways to make the point. for example:
The roofer stated the shingle damage was from wind. The roofer indicated he inspected the roof on 12/15/09. The neighbor, Mr. Jones, states that he saw a man on the roof on 12/15/09. Mr. Jones said that man appeared to be tearing shingles off the roof.
No need to accuse anyone of anything, just let facts speak for themselves, let the reader draw his/her own conclusion.
And if you're convinced the man the neighbor saw was the roofer, that's not the same as what the neighbor might have actually said. It would be wrong to say "the neighbor saw Bob Bippo, the roofer on the roof" unless that is exactly what the neighbor said. Another example, avoid saying "my expert says the roofer did it". It might be more accurate to say "My expert says SOMEONE did it" and "the homeowner says the only person on the roof was the roofer".
Be very accurate in your language when serious issues/liability is involved.
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| 12/18/2009 6:42 PM |
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ok, I chose the middle path. Wrote up the whole roof replacement and sent it to the carrier with careful reservations about COL in my report. I still get my fee and the decision is effectively shifted to the carrier.
dcmclaims
You want me to do staff adjusters job? Well, when I am on my salary and time does not matter I might, but as of now I am 100 commission, and at about 120-150 an hours that I get, investigating it is out of question.
Bobabooey
I agree with you 100%. Some "never leave my desk" staff adjusters on salary of nothing can be painfully meticulous.
Leland
If there's a fight, then it is not mine. I am neither staff adjuster, nor SIU guy. I just pass my suspicions to the carrier and let them deal with it. I am a simple guy with a truck and a ladder, and all I do well is drawing the roofs. I like it this way.
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LelandAdvanced Member Posts:741
| 12/18/2009 7:15 PM |
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All i'm saying is just be careful, no need to unnecessarily draw enemy fire. If you have to say or write anything, be circumspect in your choice of words. You can get in trouble even if you think the carrier is the only one to read your report. Assume that the roofer (and his attorney) will read your report. That's all. Good luck.
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| 12/18/2009 9:30 PM |
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$120-$150 an hour? I need to work for your company. My boss lives by the philosophy of pay his adjusters as little as possible. If he can take a few xtra bucks from you, he will.
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| 12/19/2009 9:06 AM |
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Gentlemen,
Okay, here goes and I probably will get some flak. Here is my opinion:
You have got to call the Carrier adjuster and discuss with he or she and ask how they want to handle it. Probably they will tell you to write the loss and unless you have some 8x10 glossies of the contractor AND THE INSURED OR THE INSURED removing the shingles along with affidavits from three other independent witnesses, that claim will be paid.
The insured cannot be held accountable for what the contractor may or may not have done. Non coverage due to an intentional act only relates to the insured and even then, if the risk has a mortgage on it, the roof claim will still be paid to the Mortgagee.
I would STRONGLY URGE that you DO NOT put in writing that you suspect that the contractor or the insured may have intentionally removed those shingles: Could lead to BIG TROUBLE down the line.Again CALL the inside adjuster and do as instructed. If they tell you to give your opinion then by all means do so but make sure that you start your report, "As per our telephone conversation and your directions......." or something similar.
CYA.
just my .02
Joe
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Ray HallSenior Member Posts:2443
| 12/19/2009 11:55 AM |
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O boy, We have at least two staff adjusters give a good answer to a question that comes up on roof and other claims. About 2 or 3 IA.s with many years staff and IA experience also answer "how to handle" this "odd claim" and then we have the preception of a few who question right or wrong, but only want to get paid their fee for the easy way to close a file. Yep this is proof in writing that catastrophe adjusting is a honorable profession by all so called catastrophe adjusters who post on this site. Shame.
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