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
What is the adjuster's obligation under most state fair claims practices acts when a claimant submits a proof of loss?
Answer: Acknowledge receipt and begin investigation within a specified timeframe
State fair claims practices statutes require insurers to acknowledge claims and begin investigation promptly, typically within 10–15 business days of receiving a proof of loss.
A claimant's treating physician recommends surgery, but an IME physician says it is not medically necessary. How should the adjuster handle this conflict?
Answer: Document both opinions, seek a peer review if needed, and evaluate reasonableness before deciding
Conflicting medical opinions require objective evaluation through documentation and potentially a peer review, rather than automatically favoring either physician.
In property claims, what is the purpose of a 'proof of loss' form?
Answer: To formally document the insured's sworn statement of the claimed loss amount
A proof of loss is a signed, sworn statement by the insured detailing the amount claimed and facts of the loss, and is a policy condition for payment in most property policies.
Which coverage issue arises when an insured knowingly misrepresents a material fact on an insurance application?
Answer: Rescission based on material misrepresentation
Material misrepresentation on an application gives the insurer grounds to rescind (void) the policy from inception, as if it never existed.
What investigative step should an adjuster take when a commercial property claim involves suspected arson for profit?
Answer: Engage a certified fire investigator and refer to the Special Investigations Unit (SIU)
Suspected arson requires a certified fire investigation and SIU referral to develop evidence before any coverage determination is made.
The 'made whole' doctrine in subrogation means that:
Answer: The insurer may only pursue subrogation after the insured has been fully compensated for all losses
The 'made whole' doctrine requires that the insured recover all of their out-of-pocket losses before the insurer can assert subrogation rights against the third-party recovery.
Which type of adjuster is directly employed by an insurance company to handle claims exclusively for that company?
Answer: Staff adjuster
A staff adjuster is a salaried employee of one insurance company and handles claims solely on behalf of that insurer.