Claims Investigation & Evaluation Flashcards
7 cards from real CA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Claims Investigation & Evaluation flashcards as text
Which doctrine holds that a plaintiff cannot recover damages if they were also at fault in causing the accident, regardless of degree?
Answer: Contributory negligence
Contributory negligence is a complete bar to recovery if the plaintiff had any role in causing the accident, though most states now use comparative negligence instead.
What is the primary purpose of an 'examination under oath' (EUO) in a claims investigation?
Answer: To obtain sworn testimony from the insured about the loss
An EUO is a formal, sworn examination required by most policies that allows the insurer to question the insured in depth about the circumstances of a loss.
A claimant alleges soft-tissue injuries after a low-speed collision with minimal vehicle damage. Which investigative tool is most useful for evaluating injury causation?
Answer: Biomechanical analysis correlating impact forces to injury potential
Biomechanical analysis examines whether the forces involved in a low-speed impact are sufficient to cause the alleged soft-tissue injuries.
Under the concept of 'proximate cause,' which loss scenario would most likely NOT be covered?
Answer: Mold growth occurring two years after an undetected slow leak
Long-term neglect of a slow leak breaks the chain of proximate causation; mold resulting from maintenance failure is typically excluded as it is not a sudden and accidental loss.
What does 'reservation of rights' (ROR) notify the insured about?
Answer: The insurer's intent to investigate while preserving the right to deny coverage
A reservation of rights letter informs the insured that the insurer will handle the claim but reserves the right to disclaim coverage if investigation reveals a basis for denial.
When calculating loss of income damages for a self-employed claimant, which document is most probative?
Answer: Federal income tax returns showing historical earnings
Federal tax returns provide verified, historically documented income figures that are the most reliable evidence of a self-employed claimant's actual earnings.
Which investigation technique is specifically designed to detect staged auto accidents involving organized fraud rings?
Answer: Performing a link analysis of all claimants, attorneys, and medical providers
Link analysis maps relationships between claimants, attorneys, clinics, and repair shops to identify networks that repeatedly appear together — a hallmark of organized fraud.