Claims Investigation & Reporting Standards Flashcards
7 cards from real CIA 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 & Reporting Standards flashcards as text
An auto liability claim involves a claimant who alleges soft-tissue injuries. Which investigative tool is MOST useful for identifying pre-existing conditions?
Answer: Independent Medical Examination (IME) and prior medical record review
An IME combined with prior medical records directly identifies pre-existing conditions that may affect causation and damages.
The concept of 'contributory negligence' in a liability claim investigation is important because it can:
Answer: Reduce or bar the claimant's recovery depending on state law
Contributory or comparative negligence rules, which vary by state, can reduce or completely bar a claimant's recovery when they share fault.
When preparing a claim investigation report, the adjuster should present findings in what manner?
Answer: Objectively, based on facts gathered, with analysis tied to policy language
Investigation reports must be objective, fact-based, and directly tied to policy terms to support defensible claim decisions.
A homeowner files a water damage claim but the adjuster suspects the damage pre-dates the policy period. The BEST investigative approach is to:
Answer: Order a coverage inspection, review prior insurance history, and consult a moisture or construction expert
Determining when damage occurred requires expert analysis, inspection history, and prior coverage records to establish a timeline.
What is 'index bureau' data used for in claims investigation?
Answer: Identifying prior claims history across multiple insurers to detect patterns of fraud
Index bureau databases (such as ISO ClaimSearch) aggregate claims data across insurers to reveal suspicious patterns or prior losses.
In a workers' compensation claim investigation, which document best establishes the causal link between the workplace incident and the claimed injury?
Answer: The treating physician's report connecting the injury to the described workplace event
A treating physician's medical report establishing causation between the workplace incident and the diagnosed injury is the primary medical evidence.
Which of the following is a recognized red flag for potential insurance fraud in a commercial property fire claim?
Answer: The insured recently increased coverage limits significantly and has financial difficulties
A recent significant coverage increase combined with the insured's financial distress is a classic fraud indicator in property fire claims.