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Have you ever seen an instance where an insurance company technically didn't HAVE to pay a claim, but they did so for compassionate reasons?

Asked by bearish over 11 years ago

Hi Bearish!

Truthfully, I had to think on this one for a while. To provide some context: I was nearly positive that I did have an example for you from my non-injury liability days, but you get soooo many claims in that department that I just can't remember the details of all of them (on average: 5-10 new claims a day). I wracked my brain over the weekend, asked some of my colleagues, but I couldn't think of a perfect example for you. This was as close as I could get:

As you may know, most auto insurance companies offer towing and labor (like a AAA membership) as an optional coverage on their personal lines policies. I had a claim in which my insured got a flat tire on her BMW, and used her towing coverage to get the vehicle moved to a shop where they could replace the tire. (Sidenote: we do not personally own an armada of towing trucks; most insurance companies contract out to local towing companies) However, when she went to pick up her vehicle the next day she felt that the tow truck ride had damaged the front bumper of her vehicle, so she filed a second claim for collision damages. Well collision coverage (almost) always has a deductible amount that you are responsible for. You can imagine her immediate outrage when she was informed that she would have to pay her deductible in order to get her vehicle fixed. When she explained her situation, we did do additional investigation to confirm or deny whether the damage to her vehicle was in fact caused by the tow. Among other things, we had a material damage adjuster (i.e. the guy who writes the estimates for repairs when you file a claim for either collision or comprehensive damage) go out and look at her vehicle. His determination, as well as the body shop's, was that the damage was old damage. It was not fresh. However, in order to maintain positive customer relations, we waived her collision deductible for her.

I have also had claims in which we have afforded coverage even though technically the insured did not have it at the time of the loss. This usually results from a determined mistake on our part, whether it was through the agent or one of our call centers, you name it. If we can determine that the insured should have had the coverage/would have had the coverage if not for our screw up, then in my experience we will retroactively afford said coverage.

Just remember! Every claim is different, every company is different! There are rarely any absolutes!

Hope this answers your question!

1164 Votes

What percentage of claims get denied? What's usually the reason for them getting denied?

Asked by JSB over 11 years ago

That's a sticky question because claims adjusters don't attach the same meaning to that term that you might. When I 'deny' a claim, it's most likely because there is no coverage available for the insured, usually because their policy is cancelled or they don't have the necessary coverage on their policy.

Examples:

1) You file a claim for damage to your vehicle that was caused by a hail storm. This damage is specifically covered under "comprehensive coverage". When I review the coverages on your policy, if you opted to not have comprehensive on your policy, then there would be no applicable coverage, and then I would (sadly!) deny it.

2) Let's say that you are unable to make one of your payments (whether monthly or every 6 months, however you have it arranged) for your car insurance. Most insurance companies allow a lengthy time period past your due date that you can make a late payment and not lose your coverage. Let's say that you still aren't able to make your payment, and you get a notice from your insurance that your policy has cancelled effective 1/1/2013. Let's then assume that you rear end another car on 1/2/2013. 9 times out of 10, it wouldn't matter if you make a payment immediately afterwards and got your policy re-instated. You would still most likely have a lapse in coverage and would not be covered for that loss.

There is also the issue of fraud, i.e. you lied to us. If we find out and are able to prove it, then yeah, we're probably gonna deny your claim.

In my tenure, I've denied probably less than 5% of the claims I've received. Our mantra in the biz is to do everything we can to find coverage for our insureds. I swear it's true!

1149 Votes

What's the most underhanded trick in an insurance company's playbook?

Asked by 7estelle over 11 years ago

Hi 7estelle!

To be honest I don't know what you mean. Insurance is a highly regulated industry. We don't really have the ability to be 'underhanded'. Allow me to refer to my answer to shogunn's question on 4/7/2013. Because insurance is a contract of adhesion, the ball is in our court to set the terms of the policy, and because of that we better make those terms clear! If we don't, it's a huge money and time suck to go to court, and we wanna avoid that as much as possible. And once you sign on the dotted line, you are bound to pay your premium just as we are bound to provide you up to the limits on your policy in the event of a covered loss (another biz term for you: this concept is deemed aleatory, meaning exchange is not equal, i.e. the amount you pay in premium is waaaaay lower than the amount of coverage we offer).

Basically, insurance adjusters are pretty straighforward people. The nature of our job and the service we provide doesn't allow for much wiggle room, whether on our end or yours. To prevent any misunderstanding between you and your insurance company, I highly recommend reading through your policy language, with an agent or an informed party, so that you truly understand what you're paying for.

1146 Votes

Do you ever personally feel bad for the people whose claims you have to deny, even though it's your job?

Asked by pam.stafford.gmail over 11 years ago

I would say 75% of the time, yes, because I think a lot of people just don't understand the basics of insurance: what and how much coverage you should have and how the claims process works. I myself didn't know jack about insurance before I started working in the industry. The ones I feel worst about are claims involving a delivery driver. A lot of people don't realize this, but if you work as a delivery driver (pizza, newspapers or magazines, whatever!) and you get in an accident, most of the time you will not have coverage for that loss. It's an exclusion that's written into a lot of personal lines auto policies. And we're talking a denial on both damage to your car and damage to the other person's car, if you're at fault.

But the other 25% of the time, I don't feel bad, because those claims are with people who try to cheat the system, and I just personally don't like that. Another example for you:

I had a claim where the insured had chips in the windshields of both of his jaguars. He filed a comprehensive claim on both (because that's the coverage that applies to glass damage!), not remembering that he had just taken that coverage off of his policy a couple weeks before the loss. So I broke the unfortunate news to him. He didn't really say anything and hung up on me in midsentence.

2 days later, he filed another 2 comprehensive claims. I got those claims as well since I just handled the previous two. And wouldn't you know it, he had just added comp back onto his policy. This is what he told me: That he paid to get those chips fixed out of his own pocket, and then after he added the appropriate coverage back on, dawggonnit if they didn't get chipped again! And when I asked for proof of payment on the previous chips (because crazier things have happened!) he told me that he paid cash and didn't get a receipt. Then I asked who repaired them so we could verify with them... oh he didn't know their name and didn't have their number..... so yeah....

Unfortunately we ended up paying this claim. We just didn't have sufficient evidence to deny it. But! When we do have enough evidence to deny the claim, I don't feel particularly bad about it, because well, the person lied to us!

Anyways, hope this answers your question!

1126 Votes

Do you have a set schedule for how to compensate for the loss of bodyparts? Like a foot is $2M, a finger is $300,000, paralysis is $1.5M, etc?

Asked by BRIEYO over 11 years ago

The short answer? No. Every claim is taken on a case by case basis.

And now, a longer answer for you! The injury claims I handle are Florida specific and coverage specific. As I'm sure you can imagine, insurance is an extremely complicated and red-tape heavy business, so any time you file a claim you're almost guaranteed to talk to at least 3 different adjuster, all of which handle different aspects of the claim. Me, for example, I handle Personal Injury Protection (PIP) coverage. This is your primary injury coverage if you're injured in an accident and you are insured in the state of Florida (Kentucky and Maryland and Texas have this coverage as well, but it is a state-dictated coverage, so the rules are different for each state, depending on the statute on the books). 9 times of out 10, the max limit for this coverage in $10,000. Now, if you're talking about a lost limb, that 10k is going to exhaust almost immediately. Once that coverage is exhausted, I'm done with the claim.

Now, lets say you got rear ended by a drunk driver and are paralyzed from the waist down as a result. That's what we would call a 'large loss' claim, i.e. you're never getting to your pre-accident physical condition, and you will be affected by this injury the rest of your life. If the drunk driver who hit you has insurance, once your PIP exhausts you then go to their Bodily Injury (or BI) coverage. Given the severity of the injury, it's common that that coverage will exhaust as well. Then, if you have Bodily Injury for Un or Underinsured Motorists (or BIUM) on your own policy, then you head that direction next.

In a nutshell, dollar amounts for injuries like that are estimated with several factors in mind: the degree of the injury, the degree of the recovery, the age and physical condition of the injured person prior to the accident, how the injury will affect the rest of their life/work/ etc.

I'd like to give you straight answer, BRIEYO, but as you can see, I can't, because it just depends on too many factors. But I hope that cleared up the process of settling an injury claim for you a little bit!

1116 Votes

Do you work solely with auto-related claims, or all kinds of other claims?

Asked by slowgrind over 11 years ago

Nowadays, yes. I handle injury claims that arise from auto accidents (whether the party in question is a driver or passenger in a vehicle, or a pedestrian or bicyclist hit by a vehicle) in the state of Florida.

However, prior to this position I work in non-injury liabilty claims. Still mostly auto accidents, but I did get the occasional property liability claim. During that tenure I handled claims in 7 states in the southeast: Florida, Georgia, Arkansas, Kentucky, Tennessee, Mississippi, and Alabama.

Thanks for popping my question cherry slowgrind!

1111 Votes

Will your employer scrutinize your work if they think you're approving too many claims? Surely they must have an idea of the approx percentage of claims that get denied for legitimate reasons, so do they use that to monitor adjusters?

Asked by Derelict over 11 years ago

Hi Derelict,

Like most industries our work is regularly evaluated and monitored by management. The computer program in which I handle claims has an automated notification system for my manager to follow up on my files every once and a while (injury claims stay open a pretty long time, non injury ones usually close relatively quickly).

In addition to that regular follow up system, once a quarter my manager randomly selects a handful of my previously closed files and reviews them for what my company calls "best claims practices". Basically she reviews my stuff to make sure I did everything I was supposed to. Aaaand then we'll have a meeting to discuss them, compliment sandwich style, if ya knowwaddamean :)

Hope this answers your question!

1095 Votes

Claims Adjuster

Ask me anything!

What do YOU do?

Have you ever seen an instance where an insurance company technically didn't HAVE to pay a claim, but they did so for compassionate reasons?

What percentage of claims get denied? What's usually the reason for them getting denied?

What's the most underhanded trick in an insurance company's playbook?

Do you ever personally feel bad for the people whose claims you have to deny, even though it's your job?

Also on Jobstr...

Do you have a set schedule for how to compensate for the loss of bodyparts? Like a foot is $2M, a finger is $300,000, paralysis is $1.5M, etc?

Do you work solely with auto-related claims, or all kinds of other claims?

Will your employer scrutinize your work if they think you're approving too many claims? Surely they must have an idea of the approx percentage of claims that get denied for legitimate reasons, so do they use that to monitor adjusters?

Claims Adjuster

Ask me anything!

What do YOU do?

Have you ever seen an instance where an insurance company technically didn't HAVE to pay a claim, but they did so for compassionate reasons?

What percentage of claims get denied? What's usually the reason for them getting denied?

What's the most underhanded trick in an insurance company's playbook?

Do you ever personally feel bad for the people whose claims you have to deny, even though it's your job?

Also on Jobstr...

Do you have a set schedule for how to compensate for the loss of bodyparts? Like a foot is $2M, a finger is $300,000, paralysis is $1.5M, etc?

Do you work solely with auto-related claims, or all kinds of other claims?

Will your employer scrutinize your work if they think you're approving too many claims? Surely they must have an idea of the approx percentage of claims that get denied for legitimate reasons, so do they use that to monitor adjusters?

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