Claims Adjuster

Claims Adjuster

lllawnchair

Tallahassee, FL

Female, 27

I worked at an insurance company, in claims, from March of 2011 to August 2013. (I'm now 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!

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41 Questions

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Last Answer on September 24, 2013

Best Rated

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?

Asked by Jackie almost 4 years ago

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.

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?

Asked by TonyTony almost 4 years ago

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.

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?)

Asked by 1strule almost 4 years ago

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.

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 almost 4 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!

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?

Asked by Tif718 almost 4 years ago

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 being said, there are some claims in which no one is at fault, but these are claims that usually fall under comprehensive coverage: you hit a deer, or hail damages your vehicle. When a claim like that is assigned to us we don't label any party at fault (although I have jokingly assigned 100% fault to the deer before. Oh that's right, we're a bunch of cut-ups in the insurance biz, haha). But as you may have gleaned, neither of those examples involve 2 vehicles.

Now that I think of it, there is one other example I can give you: it's called the 'act of God' defense. This doctrine usually applies to property claims: i.e. a big ass storm comes through your 'hood, and a tree on your property falls into your neighbor's yard and damages their fence/shed/whatever. When that claim gets filed with your insurance, we work to determine whether that tree was healthy prior to it falling, and if it was diseased, whether you as the insured knew it and neglected to take care of the hazard on your property. If that tree had green leaves, was totally healthy, then we would deny liability to your neighbor's damage. In short, it was an "act of God" that that tree fell, there was no way to foresee on the insured's part.

 

Hope this answers your question!

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

Asked by TonyTony almost 4 years ago

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.

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?

Asked by shogunn almost 4 years ago

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. Why? In the event that we deny a claim and you, as the insured, think... well, that it's bullshit, you can file a 'bad faith' claim against your insurance company, and basically take us to court. Now, who do you think the judge will favor in this instance? The big company that wrote the contract? Or you, the insured, who had to 'take it or leave it'? Having vague policy language has caused insurance companies in the past to pay out a LOT of damage in lost 'bad faith' cases, so it's a constant battle to make the language as CLEAR as possible. Unfortunately, we have yet to find a way to turn our contract into a veritable page turner.

For those shopping for insurance: this is where agents can come in handy. They can break down for you exactly what covers what pretty well, so you have at least a basic understanding of what coverage you should have on your policy. Or you can ask me! 

To conlude, in my personal opinion, at the end of the day insurance is a contract. Why would you not try to understand the details before you sign on the dotted line?