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I am an an old timer and spent 10 years as a senior examiner, even did time in HO. Every day I realize how much I have to learn. That is one of the joys of this industry. People take advanage of this offer and ask questions.

OK here goes:

Let's say I have a question on a claim that falls into a gray area of policy interpretation. As an examiner is it better for the adjuster to:

1) call and ask over the phone
2) send an email
3) put the question into a formal report as an official "question submitted"?

What is your preference? How do other examiners think? Is there a difference between catastrophes and daily claims?

Outside Experts:

How do examiners really feel about daily claims adjusters getting outside experts (with permission) for things like structural engineering, business income losses etc.?

Billing:

How do examiners really look at daily claims billing. Do they even look at the billing? What criticisms or concerns do they have?

Ok, I can tell you the following:

I prefer the emailing of coverage questions. The occasional direct call is ok, but you should not overwhelm your examiner with phone calls. After a while, it looks like you can't make a decision on your own. On daily claims, your question can be answered over the phone more easily because the examiner does not have a hundred files to review. Do not call your examiner unless it is an emergency during a CAT. It will irritate them I promise you.

Outside experts are just a fact of life. If there is heavy structural or foundation damage expert should always be used. Same thing applies for plumbing leaks that may or may not be sudden and accidental. Now obviously, you should not get an expert on something thats gonna be minimal damage say 0-5k. Fires always will require some type of cause an origin if they are significant. So don't worry about hiring experts, just get permission and make sure they are warranted.

I look at every fee bill that comes across my desk. This is a sure fire way to get booted if you are not being truthful about the work your doing. If your doing T & E, keep track of your time diligently. Do not fluff just because another adjuster says everybody does it. Chances are its just them and then you and both of you are gonna get the boot. The other thing thats gonna get you in trouble is on losses where you have 4,990.00 worth of damage, but you fluff the estimate to get it up past 5k for the next fee schedule. DO NOT DO THIS! you will get caught and you will be in trouble if not fired.

Posted By The Examiner on 21 Sep 2010 01:09 PM

Any adjusters out there who have either been frustrated with an examiner or can't seem to find common ground, I am giving you an opportunity to ask one anything you want.

I am a file examiner for a large company.  Do to confidentiality I am not able to give out my real name.

Questions about Xactimate, MSB and file requirements, ask away.  I realize that all examiners are not alike, but I can tell you what pushes their buttons and how you can get your files processed and approved much faster.

If your an old timer and know it all.  Just don't ask anything.

I will try and get back with folks as soon as I can.

The Examiner........

I am going to be brief and to the point, 

"What are your biggest pet peeves about adjusters in general ?"

 

Its all about attitude. Let me give you an example.

The other day I'm reviewing a file from one of our IA's. So he puts in the file that the company had asked him to climb this roof. The roof was 2 story and 10/12 so he would need a ladder assist, which generally costs about 150.00.

Well he saw no damage from his ladder, so he put in the file that he did not do the ladder assist because he 'felt' it was a waste of money.

I sent him an email stating that we needed to do what the company told us and not what we 'felt' like doing. The adjuster then called me and began chewing me out and got major attitude because he said I was disrespecting him. After I got done with him, he may not have had a rear end to sit on much less get another claim from my company.

When a reviewer gives you a set of directives, do not and I repeat do not read sarcasm or attitude into those directives. We are trying to close the claim as fast as possible so that you can get your money and go on to the next claim. Attitude is everything when dealing with folks such as myself.

Now, you may come across a green reviewer who kicks a file back to you 10 times because they won't go through the entire file and pick out all the errors at one time. In that instance, you are in the right to call that person and ask them politely and professionally to please look at the entire file before kicking it back to you. Tell them you appreciate all their hard work and that your becoming a better adjuster and learning a lot from their directives.

Do the above and you will make friends very quickly with all the reviewers you come in contact with. And, we spread news good and bad about adjusters to higher ups. (don't think we don't)

Keep the questions coming. That last one was very important.

No, do not call the Examiner unless directed by the File Examiner to do so. Instead communicate via email or thru Notes in Xactanalysis.

The fact of the matter is we Examiners are paid ONLY to review files for correctness so they are sellable to the client company. We are NOT paid to train the adjuster. We are NOT paid to counsel the adjuster. We are NOT paid to provide the adjuster with tea & sympathy. Any time we spend on the phone with an adjuster takes away time from reviewing files. When an adjuster needs training, counseling, or tea & sympathy, these are services provided by your supervisor. Call the supervisor.

When you do persist in calling Quality Control, you set yourself up as an known person, this is not a good thing as all the File Examiners learn your name and your 'attitude'. Yes, this is harsh, yet it is the base truth.

Ol' Ghost

Examiner,

   How would you feel if I came to you right in the beginning of the event and asked if you had a good sample file to go by so I could turn in a good file from the beginning , knowing what you want in a file from estimate breakdown to the reports . So neither of us have to mess around

repairing files for 2 weeks.

Would that seem out of line to you or would it be a good idea so we could both get some files closed.

Jerry, a right and proper sample file or the companies guide lines from your field supervisor is what you need. If you show up at Q.C., you may well be some 1500 miles from where the storm is. Again, trying to butter up the Examiners will get your files doubly reviewed to see what stunts you are trying to pull.

Just play it straight out there. Back in Quality Control, there are unseen forces at work you know nothing about and should never want to know.

Ol' Ghost

 

 Thanks Ghost,

 i am not a butt Kisser but I can still remember in the beginning when the reviewers were accessible right at the storm office they also doubled as ,"Counselors," you might say. WHen you are given multiple report templates to use it is not hard to use the wrong one sometimes.

   No adjuster likes getting a file kicked back for something as using the wrong template. Especially if you are turning in 3-8 files per day. It is the quickest way to lose a day or two making corrections and getting behind .

   These little details mean the difference between becoming proficient and turning in good files or ,especially if you are a beginner digging yourself into a nightmare.

 I have always prided myself in being in the top 10% of the adjusters  for several reasons. I just want to turn in the best product for the vendor & Carrier so when my name comes up for deployment it's a no brainer who they call.

  

It seems I have a co-counsel now in the Ask the Examiner Forum. Great! now you can get two perspectives.

In answer to your question, Jerry I think every good (no) great examiner should have a sample file ready to go for all of his/her adjusters that come in.

While it is not our responsibility to train you as my counterpart said, it is our responsibility to give you all of the important information that you need prior to kicking you out into the field.

Now, with that said not all examiners are going to have this information on them. If they do not have a sample file, you need to make your own on the first claim you get passed through with flying colors. In a step in the right direction, you may also want to email a copy of that completed report (with all of the names and address' changed to generic names) to your examiner so that then they could distribute that to the other adjusters. That would be a little feather in your cap.

Ray, unfortunately buddy the days of you buying me a dinner to get your poorly written or trouble file passed as gone. I myself do not and will not have lunch, dinner, drinks or go to the local club with any of my adjusters. That is bad business. Now if you were just making a funny observation then LOL! but don't let anyone reading this think thats the way to get in. Its not! Do a good job, be on time, work hard and have the utmost integrity and morals.

The Examiner

Like Examiner, I will remain a little anonymous as well. My position for a leading national independent contractor is large loss and complicated claim examiner. Most files I see are T & E invoicing, and my biggest complaint isn’t that the adjuster is padding his worksheet, it’s that it is obvious that the worksheet was created when the adjuster was preparing to close his claim assignment. That’s when things begin to appear creative. It’s amazing how fast those tenths of an hour add up on large losses.

Really, my first complaint is that I constantly see work from adjusters that they have not been proofed. Getting a report with the wrong LOGO, poor grammar, no spell check, etc.etc … will make an examiner nuts.

Report  writing is probably the weakest point of good property adjusters who come out of the contractor field. I had to write reports for years as a casualty adjuster and got by. In a 4 year span I worked Oil & Gas losses onshore and off, property and liability. It would take one to two days to write a report that was around the world and read by hundreds, plus 2  or 3 other people in your office. I improved greatly. I never dictate. I longhand at least 2 times before the word processor and 4 other eyes see,s the report.

Examiner, Ghost, Blu,

Thank you for stepping up to the plate and offering yourselves as a resource. This is a much-needed and greatly-appreciated service. For personal reasons, my involvement here at CADO has been sporadic in the last year. However, my position these days is as the guy who hands out the claims to independent adjusting firms and reviews the files when they come back in for payment or denial. My title is Claim Analyst, but some of the functions are the same as a carrier examiner. So, I'll chime in here and add my 1.5 cents.

Jerry, when someone gets their first assignments from our company they get with it a document that includes the file standards and expectations of our company. I am intimately acquainted with these standards since I wrote the document in the first place (though I used a GAB Robins TAS as a template). Anyone who wants to know what a report to us should include would only have to read the document and use normal common sense about photo quality and things not mentioned in the document.

Most carriers have some written standards that should be in the possession of the independent for whom you are working: Here is ours (edited to remove my company's name and replacing it with XYZ). Bear in mind this only applies to our company. Each carrier will have different standards. Get used to that. It is a fact of life. All of our business is commercial, so the standards are different than for homeowners claims.  This is our standards for daily claims. Our standards for CAT claims will be different and are in the process of being written. By far the most violated part of this document is #15.

1. Company Mission: The Mission of XYZ is to elevate agents in the eyes of
their clients. When handling a claim as a representative of XYZ, we ask
that you also assist us in the fulfillment of our mission. Please keep the agents and
brokers “in the loop” as you handle claims for our insureds. Treat agents with the
utmost respect, and allow them to help you in the resolution of the claim on the
insured’s behalf. We are on the same team, and the agent can be a powerful ally
in settling the claim.
2. Assignments: Many assignments will be accompanied by specific instructions. In the
absence of specific instructions, assignments should be accepted as full adjustments.
Accept claims only from the claim department of XYZ.
3. Coverage Verification: XYZ will supply necessary documents and policy forms to
indicate coverage and alert the adjuster to potential coverage questions. XYZ will
make all coverage determinations. The adjuster is not to commit XYZ to coverage.
Handle all claims where there is a question of coverage under a non-waiver or
reservation of rights.
4. Reporting Requirements: Contact Insured within 24 hours. Acknowledgement within
48 hours. First Report within 20 days. Scope and cause of loss with reserve
recommendations should accompany first report. Subsequent Reports: Every 30 days
unless otherwise requested by XYZ. Contact XYZ immediately upon inspection if
reserve will exceed $100,000.00 or if any issue of coverage or possibility of SIU
involvement is discovered.
5. Settlement Authority: Unless otherwise instructed, the assigned adjuster has no
settlement authority.
6. Checks: Issued by XYZ.
7. Reports: Reports should be full captioned reports with all supporting documents
attached.
8. Billing: All assignments should be handled at time and expense according to our
agreed rates. Phone and fax charges are included in the hourly rate. Set up should be
charged at clerical rates not to exceed one hour.
9. Statements: Statements should be taken when requested by XYZ.
10. Subrogation: Investigate subrogation on all claims. Preserve all evidence. Inform
XYZ immediately if an expert is needed for subrogation investigation.
11. Photographs: One photo of risk and enough photos to document the damage, or lack
of damage where damage might be expected.
12. Experts: XYZ’s approval required. In many cases XYZ will ask the expert to report
directly to them.
13. Public Records: Only if advised by XYZ.
14. Value: If requested to do so, provide detailed calculations to demonstrate Replacement
cost, depreciation and ACV.
15. Estimate: Whenever possible, the adjusters are to prepare their own estimate
using an automated estimating program including both RCV and ACV figures.
This should be done whether there appears to be coverage or not. Do not release
the estimate to the insured before we approve it. In most cases a preliminary
estimate should accompany the first report. Each line of coverage and element of the
loss is to be written as a separate estimate. Do not include more than one building, or
building and business personal property, on the same estimate. When the loss involves
specialty items that are not generally included in the database of automated estimating
programs, it is acceptable to use reasonable contractor estimates. If a portion of the
loss may not be covered, prepare a separate estimate for that portion of the loss.
16. Business Personal Property/Contents: Use of replacement vendors should be
considered on large business personal property claims. Consult with the XYZ examiner
for qualified replacement vendors.
17. Salvage: Always investigate salvage. When possible sell it back to the insured for a
reasonable amount. Otherwise, inform us of salvage potential and advise the insured to
retain the salvage for our disposal.
18. Proof of Loss/Release: Obtain a proof of loss or release if instructed to do so by XYZ.

Steve, If I may make some comments on your post. Thanks for sharing that, its great info.

#3 is great, not all carriers think to provide policy info.

#6 does check get mailed directly to the insured, or sent to the independent's office for the independent to re-send? If the check is mailed directly to the insured, does the independent get a copy? Spelling out this procedure will avoid confusion for an adjuster who hasn't done many claims for you. Also if it says the adjuster will be copied on settlement checks, it will make the adjuster comfortable to call and say "hey, did a check go out? - I didn't get a copy". That's better than having a mystery about whether a payment is being issued.

#7 maybe you could mention if there are any standard captions that you expect to see on every claim like "Salvage" and "Subrogation"

#9 How do you prefer statements or do you have a preference? Digital tape OK, or should it only be a cassette tape? If a cassette do you want the original tapes sent or maybe you will advise as needed. Do you want statements always/sometimes/never transcribed or "will advise".

#10 who sends subro demand letters? adjuster advises and you send letter or OK for adjuster to send initial demand letters?

#18 who prepares the POL? You or the independent? About half of the carriers I work with want me to fill out my own document, the other half sends me the form already filled out. Also you might want to give a guideline, for example:

"XYZ will advise if we want a Proof of Loss obtained. As a general rule, we will ask for a proof on any claim with subrogation potential."

Just my two cents, maybe you will like one of these ideas, every company of course has it own method.

One more point. Some carriers like adjusters to send denial letters, at least on some claims. Believe it or not, some carriers are very comfortable with it or even expect it especially on certain types of routine denials.

If a carrier does NOT want adjusters writing denial letters (like most carriers) it might be a good idea to say so to avoid any misunderstanding.

Also for California especially it might be good to specify who is expected to write the 30 day status letters to the insured or claimant. Some carriers send their own letters, others depend on the adjuster to send the letters to comply with Calif Fair claims rules.