Chapter 6: The Claim Function Flashcards
1
Q
Claim Function Goals
A
- Complying with the contractual promise
- Supporting the insurer’s financial goals
2
Q
Claim Information Users
A
- Marketing
- Underwriting
- Actuarial
3
Q
Claim Department Contacts
A
- The public
- Lawyers
- State regulators
4
Q
Claims Department Structure- Claims Personnel
A
- Staff claims representative
- Independent adjusters
- Third-party administrators
- Producers
- Public adjusters
5
Q
Measures Used to Ensure Regulatory Compliance
A
- Claims guidelines, policies, and procedures
- Controls, such as reports, access security, authority levels, and tracking
- Supervisor and manager reviews
- Claims audits
6
Q
Activities in the Claim Handling Process
A
- Acknowledging and assigning the claims
- Identifying the policy and setting reserves
- Contacting the insured or the insured’s representative
- Investigating and documenting the claim
- Determining the cause of loss, liability, and the loss amount
7
Q
Six Common Methods of Setting Reserves
A
- Individual case method
- Roundtable method
- Average value method
- Formula method
- Expert system method
- Loss ratio method
8
Q
Types of Claims Investiagtions
A
- Claimant investigation
- Insured/witness investigation
- Accident scene investigation
- Property damage investigation
- Medical investigation
- Prior claim investigation
9
Q
Claim Documentation Components
A
- Diary systems
- Activity logs
- File reports
10
Q
Framework for Coverage Analysis
A
- Is the person involved covered?
- Did the loss occur during the policy period?
- Is the cause of loss covered?
- Is the damaged property covered?
- Is the type of loss covered?
- Are the amounts of loss or damaged covered?
- is the location of the loss covered?
- Do any exclusions apply?
- Does other insurance apply?
11
Q
Exclusions to Coverage Can Include
A
- Persons
- Causes of loss
- Types of property
- Types of damage
- Other circumstances
