Claims Investigation & Evaluation Flashcards

A claimant alleges injuries from a slip-and-fall at a retail store. Which element of negligence must the claimant prove first?

Answer: That the store owed the claimant a duty of care

The first element of negligence is establishing that the defendant owed the plaintiff a legal duty of care based on their relationship and circumstances.

Under the 'collateral source rule,' an insurer paying a bodily injury claim:

Answer: Cannot reduce the liability claim payment because the claimant received benefits from an independent source

The collateral source rule prevents a tortfeasor or their insurer from reducing damages because the plaintiff received compensation from an independent third-party source.

In evaluating a homeowner's water damage claim, the adjuster determines that slow, continuous seepage caused the loss. This is most likely:

Answer: Excluded as a maintenance issue or gradual damage under standard policy language

Standard homeowner's policies typically exclude gradual seepage, leakage, or continuous water damage, covering only sudden and accidental losses.

What does a 'field investigation' typically involve in a property claim?

Answer: A physical inspection of the loss site to document damage, verify facts, and gather evidence

A field investigation involves the adjuster physically visiting the loss location to inspect damage, photograph evidence, measure affected areas, and verify the claim facts.

When calculating lost wages for a liability claimant, which document provides the most reliable verification?

Answer: Employer verification letters and W-2 forms or tax returns

Employer verification and tax documents (W-2s, tax returns) provide objective, verifiable income data that is the standard for lost wage calculations.

A policyholder files a claim for a stolen vehicle but cannot produce proof of purchase. The adjuster should:

Answer: Request alternative documentation such as title, registration, financing records, or prior insurance documents

While a purchase receipt is ideal, multiple alternative documents can establish ownership, and the adjuster should request all available evidence before making a coverage decision.

What is 'comparative negligence' and how does it affect a liability claim payment?

Answer: It allocates fault between parties, reducing the claimant's recovery by their percentage of fault

Comparative negligence apportions fault between parties, so a claimant found 30% at fault would recover only 70% of total damages from the defendant.