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Claims Adjuster

Claims Adjuster
Name:lllawnchair
Location:Tallahassee, FL
Gender:F
Age:27
I worked at an insurance company, in claims, from March of 2011 to August 2013. (I'm not back in grad school) I've got experience determining liability (or fault) in 7 states in the southeast US, as well as injury (Personal Injury Protection or PIP) claims in Florida.

**Disclaimer!** I am NOT qualified to give legal advice, so don't ask!

Find me online: My website
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Q
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?
A

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

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

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

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
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Q
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?
A

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
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Q
What are some tips that can save people money on their car insurance that aren't widely known?
A

Hi Dipsy!

The cost of your car insurance depends on a whole lotta factors: the state you live in, where in that state you live (urban, suburban, rural), the kind of vehicle you drive, your driving history and the history of any other listed driver on your policy. 

The best I can say is, don't lie on your application. Bad, bad idea. If you do, you risk the insurance company finding out if/when you file a claim, and then you would be investigated for "Material Misrepresentation". What that means: whether knowingly or not, you misrepresented yourself as an applicant to the insurance company, and because of that they were not able to appropriately assess your premium. Exampes I've seen: not listing a resident relative as a driver on your policy because mayhaps they
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Q
Seems to be a lot of confusion between what people are covered for vs. what they *think* they're covered for. How much of this do you think is caused by customers' ignoring of the fine print, vs. insurance policies being really confusing/unclear?
A

Hi shogunn!

In my opinion it's 50/50. As I've said before, insurance is a complicated business. Our contract language is admittedly pretty dry. Here's the main reason why: One of the aspects of an insurance contract is that it is a contract of adhesion. This basically means that we, as the insurer, write the terms of the contract and you, as the insured, do not have the ability to negotiate that language. In layman's terms, you take it or leave it (this is not the same as choosing the limits of your coverage, which of course you have control over). Now, although watching a snail push an acorn may be more interesting than reading through your policy documents, if you pulled up your current auto contract and read it, you may notice that we actually try to make it as unvague as possible.
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Q
Do you work solely with auto-related claims, or all kinds of other claims?
A

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! 

Q
Is the "jump in front of delivery vehicle / sue his employer" scam still popular?
A

Hey again TonyTony!

Haha, again, I've never heard of that. I've never had a claim like that. In my experience, delivery drivers (if you're talking about pizza/newspapers/that kind of thing) don't usually have insurance through their employers.

Q
Even though I assume insurance companies can't charge different rates to people of different races, are stats kept internally on that stuff, and care to share to confirm / dispel some, um, common stereotypes?
A

Hey Tonytony!

I, personally, have never heard of that. The premium a driver is charged is determined by a myriad of factors: the state they live in, their driving history, whether they have a loan out on their vehicle, among many other  things. 

And as far as stereotypes go, in auto accidents I don't believe in them anymore, haha. Sometimes everyone's a crappy driver.

Q
If there's a rear-end collision, is the driver in the back automatically liable? Can "the guy in front of me stopped too suddenly" ever be a legitimate excuse?
A

Well, I can never say 100% YES, every single time! But honestly? 99 times out 100, yeah, I've assigned 100% liability to the rear vehicle. Why? Well, because technically if you were maintaining a safe distance for conditions, you should have been able to stop in time to avoid the collision. What if the guy in front of the front car stopped suddenly? And they were able to stop but you were not? 

Hope this helps JessP!

Q
What responsibilities do witnesses to an accident have? If I see a car crash, do I have a legal responsibility to wait around for the cops? What if one of the reasons the crash happened was because a car was swerving to avoid me?
A

As far as I know (remember, I ain't a lawyer!), witnesses do not have any responsibility to stay at an accident scene to talk with the police. Do I think it's a good idea? Yeah. You, as an unbiased party, can either defend or refute a driver's description of what happened. As you can imagine, sometimes people are less then honest in terms of admitting fault at the scene, so it definitely helps a liability adjuster determine fault if they've got your information and can get a statement from you.

If an accident happened because a vehicle was trying to avoid you, then I would answer your question with another question: What were you doing wrong?? ; ) lol, j/k. But seriously, if you think you contributed to an accident, what does the good samaritan in you think is the right thing to do?
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Q
When two drivers both do something wrong - let's say one runs a red light, but the other guy is driving 100mph, who is at fault? Don't some States have a system where you're not allowed to divvy fault up, but it's all or nothing by law?
A

Hi DomNJ! What you're talking about is a negligence doctrine, which varies by state. In the state of Florida (as well as Kentucky and Mississippi) we have whats called "pure comparative": after a liability adjuster completes their investigation, they divide up fault by percents (although a lot of the time it's 100% one person's fault or the other, or 50/50) In Florida, what percentage you're found NOT at fault, thats the amount of your damages you can get back (or subrogate) from the other party (usually via their insurance company). So, lets say that you are in an accident in which you're found 50% at fault. This means that you can get back 50% of your damages back from the other insurance company (50% of your deductible, and then your insurance company can pursue to get 50% back of what ...More

Q
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?
A

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!

Q
Is that explanation Ed Norton's character gives in Fight Club about how car makers determine whether they'll do a vehicle recall accurate? (That they'll leave an unsafe car on the road if the recall would cost more than paying the injury claims?)
A

Hi 1strule,

As much as I hate to admit it: I have absolutely no idea. I've only ever handled personal lines insurance claims, and it sounds like this one falls totally outside my area of experience. I would imagine an adjuster who works in commercial claims would have a better idea of whether or not thats true, but all my colleagues are in the same boat as me.

My gut tells me, however, that that is either exaggerated or totally false. Injury claims are biiiiiiggggg liabilities, whether its a personal or commercial auto policy.

Q
Are there some cases where NO ONE'S at fault? Say an airplane part falls from the sky, a car swerves to avoid it, and hits another car. Complete freak accident / no way to foresee. Does the US insurance system REQUIRE the assignment of SOME fault?
A

The short answer? It depends...

This is where you get into the territory of difference of opinion between adjusters. Some would say that even though it's not that first car's fault that some random object same into their path, they were still negligent in that they failed to maintain control of their vehicle and hit the other car. And how would you feel if you were in that second car? There you are just driving along when this other car comes out of nowhere and damages your vehicle. And if the adjuster assigned to your claim says, well, in this case no one's at fault, it was a freak accident, you're still stuck using your collision coverage to get your vehicle fixed, and you still have to pay your deductible, even though you contributed in no way to this accident!

That
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Q
I always wondered whether I could leave my car in a bad neighborhood with the keys still in it and then file a claim when it inevitably gets stolen. It technically DID get stolen, right? Even though I kind of "facilitated" it.
A

Hi Jofredab! Sorry it's taken me so long to answer your question; for some reason the insurance biz has been busy lately!

Here's the rub with your particular example: intentional act. Most personal lines insurance policies have an exclusion for first party coverages (collision, comprehensive) and third party coverages (property damage, bodily injury) f it is discovered that the loss was some how intended by the insured. (Much like how suicide is often an exclusion for benefits on a life insurance policy). Another example that I actually have seen before:

Lets say you are in a very um... for lack of a better word, volatile romantic relationship. Lets say that you cheat on your significant other, or they suspect you of cheating, it doesn't really matter, the
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Q
Is working in insurance fun? What type of personality do you think is the best fit for what you do?
A

Well, Jackie, if I'm being honest? NO! It's boring, repetitive and stressful. Afterall, what 5 year old says, 'When I grow up, I wanna be a CLAIMS ADJUSTER! Yeeeaaaayy!' That being said, it takes all kinds to make the world go round. I work with people who have been with this particular company for decades, and they seem very content.

In Florida especially, there's a lot of problems with insurance fraud. I think someone who's detail oriented and very into the investigative nature of claims would thrive in this environment. And there is a certain part of me that does enjoy the customer service side of my job. I help people understand their coverages and provide them a sense of comfort during a very tumultuous experience. Car accidents are never convenient, and they are guaranteed to
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Q
How often does your company get sued, and do you know how often they settle out of court?
A

Honestly Borat, I just don't have access to that kind of info.  Those kinds of claims are handled by a special, highly experienced, unit, and they usually don't send company-wide emails about a suit's progress.

I can't say for sure, but I would guess that in most cases like that, both parties would rather settle out of court: it's just less expensive and time consuming.

Q
Thanks for answering my first question and for doing this Q&A! Do insurance companies ever hire private investigators to spy on a person to see if he's just faking his injury to get a settlement?
A

Hi Jackie!

As far as I know (I've only worked for 1 insurance company to date), most insurance companies have a special invesigation unit for claims in which they suspect foul play of some sort. This unit is usually comprised of retired police officers, detectives, that kind of thing. If an insurance company suspects that a claimant is exaggerating or faking an injury, I have heard of the adjuster referring the claim to that special unit to do surveillance on the claimant to see how their supposed injury truly affects them when they go about their day to day business. Have I every had a claim like that? no. But I have heard of it.

Q
I have a collector car that has damage to the front bumper. The repair shop said the replacement stripes would not match the rest of the car due to age of the existing stripes on the hood and trunk. Should I be able to claim new stripes for the car?
A

Hi Rob,

I know that collector cars often have specialty insurance policies due to their age and intrinsic value. I have not dealt with claims involving those kinds of policies, so I can merely speculate as to the specifics of what is covered. That being said, most of the time your auto insurance is not for claiming upkeep and/or maintenance on your vehicle. Usually you are only covered for damage to your vehicle that's caused by a 'covered loss', i.e. an accident involving another vehicle, fire/hail/water damage, etc. In most personal lines auto policies there is an exclusion for first party coverages (collision, comprehensive) if the auto is damaged due to wear and tear (also freezing, and damage as the result of a war, fun facts!). I would say that most likely that kind of upkeep
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Q
Is "whiplash" an actual provable injury, or just something that people claim in lawsuits?
A

Hi Denise,

Whiplash is a common (non-medical) term describing a range of injuries to the neck caused by sudden movement. It's not a diagnostic code as far as I know; usually the diagnosis is described as a 'cervical sprain/strain' or something like that. It's a common injury in rear-end accidents. For example, let's say you were sitting in traffic and a vehicle hit you in the back. Due to physics (or some other fancy science-y phenomenon.... my worst subject in school, can you tell?) you will always travel in the direction of the impact. That, in conjunction with a head rest that is not properly positioned behind your head, may cause your head to jerk back suddenly, and then forward again, thus causing a sudden, extreme movement of your neck, which can cause injury.

Hope
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Q
Do claims adjusters go to the actual scene of an accident, or is it only the police who do that?
A

Hi MissPink!

To my knowledge, the first responders to an auto accident are always the police and/or medics. Claims adjusters rarely go to the actual scene of an accident. We may request photos if they are available, or utilize a bird's eye view of the area, if liability is in question. After all, when I handled non-injury auto claims, I worked in 7 states of the southeast, all from the (mild) comfort of my little cubicle!

Q
This is regarding Florida No fault PIP coverage, I live in PA and just received Florida adjuster license. I am paying the $10,000 limit and need an exhaust letter to send with it. Do you know where I can find this and other FLorida PIP letters?
A

Hi DEB, honestly I always used company written letters. I rarely crafted my own letters. Most companies have an in-house counsel that drafts our letters for us. Sorry!

Q
I was involved in a minor accident using my husband's parents' car, under which he is covered. We also have another car under separate auto policy. The claims adjuster of my father-in-law's policy is asking me for my other auto policy number. Why?
A

Hi Tina,

Most likely it's a required procedure on the part of the claims adjuster. You have it right that, as you were driving a car owned by your father-in-law, his insurance would be primary. For a minor accident (if it was determined that you were at fault), his coverage should be fine. However, there can be exceptions, including the following: Lets say that for whatever reason, your father-in-law's policy wasn't active on the date of loss. At that point the other person's insurance could pursue your insurance (since you were driving) for damages.

Although, most likely it is just a procedural thing: if a claims adjuster finds out that someone was driving your car that isn't listed on the policy, they tend to get more information to let our underwriters (our risk assessors)
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Q
i was in a eating in a business and a guest tripped and fell on my table,the table broke and the table and the customer fell on me at the time i thought i was ok but now im hurting can the establishment be liable for my medical and my clothes
A

Hi Janet,

Possibly? I honestly don't know for sure, since I only handled auto claims and personal property claims (no commercial). Depending on how long it took you to feel any pain and whether or not you've sought treatment for any injuries, you may be able to request reimbursement for medical costs. 

Q
I was rear ended by a drunk driver he was driving his girlfriend's car I was compensated from her insurance however he didn't have insurance so it fell under my uninsured motorist coverage my insurance wants to meet with me to discuss my injuries why
Q
Lets say your driving and your in the turning lane to make a left turn & a car in front of you not in the turning lane decides to back up into the turning ln & hits the car already in turning lane who is at fault
Q
I have a 3rd party claim and adjuster sent me (under my name) a full & final check based on initial estimate. What happens if body shop finds more damages? Adjuster knew the shop where the car will be repaired and rental car is even set-up by them.
Q
In 3 car chain accident in AZ. I was middle car. Driver hit me from behind. Their ins offering 50% for my car damages. Is this reasonable?
Q
I backed out of my driveway and hit a car that was illegally parked on the cul de sac.he suggested that he might be able to pop the pushed in door back.got no police report. Now he says he is taking it somewhere to be fixed. Does ge have any fault.
Q
the other party adjuster wants to settle for 50/50. but its was not our fault. what to do about disbuting it
Q
Can I claim damages for money I spent while in the hospital after a slip and fall for money spent to take care of my legally blind significant other - we've been together for 35 years.