Claims Investigation & Evaluation Flashcards
7 cards from real CCP 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
When a claimant refuses to submit to an Examination Under Oath (EUO), what is the most likely consequence under a standard property policy?
Answer: Coverage may be voided due to breach of policy conditions
Most property policies require the insured to submit to an EUO as a condition of coverage, and refusal can constitute a material breach that voids the claim.
A claims adjuster discovers that the date of loss reported by the insured does not align with weather records. What is the best next step?
Answer: Obtain certified weather data and request clarification from the insured
The adjuster should document objective weather records and give the insured an opportunity to explain the discrepancy before drawing conclusions.
Which document is most useful when investigating whether a business income claim loss amount is accurate?
Answer: The insured's prior-year tax returns and financial statements
Tax returns and financial statements provide objective historical revenue data needed to project the business income loss during the interruption period.
In a liability claim, what does 'proximate cause' mean?
Answer: The direct and efficient cause most closely linked to the loss
Proximate cause is the primary cause that sets in motion the chain of events leading to the loss, determining legal liability.
A recorded statement is best obtained from a claimant:
Answer: As early as possible in the investigation while details are fresh
Early recorded statements capture details before memories fade and before parties may be influenced by counsel or other parties.
When evaluating a soft-tissue injury claim with no objective medical findings, an adjuster should:
Answer: Evaluate the claim based on subjective complaints, treatment records, and credibility factors
Soft-tissue claims require holistic evaluation of subjective complaints, consistency with the mechanism of injury, treatment history, and overall credibility.
What is the primary purpose of an Independent Medical Examination (IME) in a claims investigation?
Answer: To obtain an objective medical opinion on injury causation, extent, or treatment necessity
An IME provides an independent, objective medical assessment that helps evaluate causation, appropriateness of treatment, and degree of impairment.