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84 Cards in this Set
- Front
- Back
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Representational Documents |
1.Photos 2. Videos 3. Maps 4. Diagrams |
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What information should be included with a photo in a claim file? |
-Photographer's name -Date photo taken -Time of photo -Whether artificial light was used -Type/Speed of camera -If flash used -Name of insured -Policy # -Claim # |
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Direct Questions |
Seek brief answers |
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Open-Ended Questions |
Questions seek detailed answers |
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7 Part Method |
1.Permission & Intro 2. Identification 3. Setting 4. Incident 5. Post Incident injuries/damages 6. Miscellaneous 7. Conclusion |
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How should statements be organized |
7 Part method; Body of statement should adapt to different type of losses and contain info specific to that type of loss |
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Qualities of Effective Statements |
Coherent Complete Objective |
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What is advantage of video statements |
Reveals physical characteristics of interviewee, visible injuries, body language and expressions
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What are advantages of recorded statements for claim reps? |
Saves time, get account of claims from interviewees own words, allows claim rep to ask questions and get more in depth info |
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What is the advantage of written statement |
More easily admitted into evidence than recorded statement |
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Leading Question |
May requier yes/no answer, gives no explanation of details |
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Sworn Statement |
Signed records of event as told by interviewee, declaration of truth |
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Examination Under Oath |
Statement given by a who has sworn to tell truth before officer of court |
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EUO |
Examination Under Oath
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Deposition |
Pretrial discovery tool involving oral examination of a witness to produce written verbatim record |
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What is the major reason for obtaining a sworn record |
Legal requirement to be admissible as evidence in legal proceedings |
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Describe an Affidavit? |
A sworn written statement |
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Compare recorded statement to an EUO |
EUO is more formal than recorded statement |
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How are recorded statements taken |
By claim rep typically by phone |
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How are EUO taken |
By attorney for insurer usually at insurer's office, or court reporters office |
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How is proof of loss taken |
Claim rep mails to insured; insured signs and notarizes it; then mails back to insurer |
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When are examination under oath used? |
Whenever serious questions exist about the validity or extent of injury or damages in a claim |
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When are depositions obtained |
Used as part of discovery in a lawsuit |
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Types of sworn statements |
Deposition Recorded Affidavit Proof of Loss Examination Under Oath
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Recorded statements, often time are the only type of sworn statements in ______________ claims |
Commercial General Liability |
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Exception... ________________ claims typically require insureds only to cooperate |
Worker Compensation |
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___________ gives the insurer opportunity to see how insured will do in litigation process |
EUO |
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___________ can be added to a recorded statement |
Affidavit |
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It's almost never advisable to ... |
subsequent deposition in exchange for recorded statement |
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Easily admitted into evidence |
Written Statement |
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Types of statements taken during investigation |
Recorded Written Investigation |
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Spoliation |
Failure to preserve property for another's use in litigation |
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What can spoliation lead to |
Spoliation claim |
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Disadvantage to allegations of spoliation to evidence |
delay claim resolution, complicate litigation, influence jury verdict |
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Spoliation Claims are usually raised as ____________________ . |
defense in court proceedings |
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What is needed to show evidence has been improperly lost or destroyed |
Proof |
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Spoliation in tort is precluded by the... |
Exclusive Remedy Rule |
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Remedies for Spoliation |
-Dismissal of Case -Adverse inference -Sanctions; court imposed sanctions -Exclusion of any evidence relating to missing evidence |
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Advantage to video |
powerful means to explain how events occurred; sometimes used to establish claimants physical ability |
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Should be prepared by professionally trained surveyors or engineers |
Maps |
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What should be included with a photo |
photographers name, date and time of photo, whether artificial light or flash used |
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What should be attached to certain photos |
measurement & description with things like skid marks, broken pavements, pot holes |
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digital photos are easy to _________ |
copy and alter |
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For serious claims photos should __________ |
be taken by professional photographer, experienced investigator, or person who has involvement in the case |
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Representational documents |
Photographs Maps Diagrams Videos |
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Two general uses of photos in a claim file |
Demonstrative evidence, and document an investigative technique |
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What elements typically demonstrated in auto accident scenes made for claim investigations? |
streets, direction of vehicles before and after accident, obstructions to view, grade of street, and location of traffic lights |
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Diagrams are included in claim files as _______________________. |
visual aids to communicate or clarify the events that gave rise to a claim |
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NCCI |
National Council on Compensation Insurance |
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Internal Managers use claim data to |
Make decisions on pricing, underwriting, reserving, and investing |
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Actuaries use claim data to |
Supply info required to calculate insurance rates, develop rating plans, and estimate loss revenues |
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ASOP |
Acturial Standard Of Practice |
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Advisory Services use claim data in |
The development of prospective loss cost, standard insurance policy forms, and develop policy forms, endorsements, and rating systems . |
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AAIS |
American Association of Insurance Services |
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Statistical Agents use claim data to |
Report aggregated info to the state insurance departments |
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Regulators use claim data to |
Determine if rates are adequate, not excessive, not unfairly discriminatory. |
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Regulators collect data by |
State, Class, and Coverage |
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Stakeholders Who use Claim Data |
Regulators, Statistical Agents, Advisory Services, Actuaries, and Internal Managers |
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What will happen if information claim rep enters is incomplete/inaccurate? |
This will affect the accuracy and completeness of aggregate data that are used as a basis for important business and regulatory decisions |
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Basic characteristics of good quality management |
Accuracy, Validity, and Completeness |
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Data Quality Management includes: |
The reporting, analysis, and interpretation of data |
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Data Quality Problems |
Data errors Missing data & Null values Duplicate transactions Default values rather than actual values |
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First Principle that determine the quality of data |
Data are appropriate for the intended use |
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Second Principle that determine the quality of data |
The data are reasonable and comprehensive |
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Third Principle that determine the quality of data |
Methods used to obtain data are appropriate and any material limitations of the data are addressed |
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Loss History |
Listing of past claims including DOL, line of business, type/description of claim, amount paid/reserved |
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Loss Reserves |
an estimate of the amount insures expect to pay in the future for losses that have already occurred and been reported but not yet settled |
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Loss Ratios |
Ratios that measures losses and loss adjustment expenses against earned premiums / & that reflects premiums being consumed by losses |
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When bodily injury claim is filed by medicare elgible claimant or plaintiff the insurer/self insured organization is required to electronically submit info on the identity of the claim to |
Center of Medicare and Medicaid Services |
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US Medicare, Medicaid & SCHIP Extension Act of 2007, se 111 created a mandatory reporting requirement of |
Self Insureds |
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ISO's offer a vast number of services and products to support insurance risk management by providing... |
Statistical, acturial, underwriting, claim, and compliance services |
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NICB |
National Insurance Crime Bureau |
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What is the NCIB, and what do they do? |
Non profit organization dedicated to preventing, detecting, and defeating insurance fraud. |
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N.M.V.T.I.S. |
National Motor Vehicle Title Info System |
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Bodily Injury Reporting |
Helps develop statistics |
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How are statistics related to Bodily Injury reporting |
Info is used to properly staff workers compensation, and develop state safety codes and various workplaces |
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Workers Compensation Statistics |
Is used to develop the US OSHA laws, and general safety requirements and reccomendation |
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NCCI |
National Council & Compensation Insurance |
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What is Auto Accident reporting used for? |
Used for statistics that form the basis of laws regarding minimum auto liability limits, no fault laws, and similar regulations |
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Fire losses are reported to who by insurers |
Fire Marshal |
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Child Support enforcement reporting is |
Claims payments are redirected from individuals who are delinquent on child support payments |
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Statistics from Fire reporting |
Used to help states determine the # of fire stations and amount of equipment needed to protect communities . |
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Statistics from Fraud reporting |
State and federal governments use insurance fraud stats to develop fraud detection, investigation, and prevention services |
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OFAC |
Office of Foreign Asset Control Reporting |
