1. Claims Adjusting Objectives Definitions
Complying with contractual promise
Achieving profit objective
Collection of information
Marketing
Underwriting
Actuarial
Definitions
First party = claims by policyholder
Third party = claims against policyholder

2. Claims Environment External Internal General public
Plaintiffs’ attorneys
Defense attorneys
State regulators
Licensing
Consumer complaints
Market conduct audits
Unfair claim settlement practices legislation
Documentation
Communications
Settlement standards
Internal
Marketing
Underwriting
Legal
Training

3. Organization of Claims Function Physical Organization
Centralized/decentralized
By product or line of business
Personal/commercial
Property/liability

4. Organization of Claims Function Management Structure
Claims managers
Examiners
Supervisors
Adjusters
Independent adjusters
Producer claim services
Public adjusters
Other claim personnel
Cause and origin experts
Appraisers
Reconstruction experts
Private investigators
Rehabilitation experts

5. Claim Adjusting Process
Questions
Is the loss covered?
Is the policyholder or insurer legally liable?
What are the damages?
Coverage
Insuring agreement
Exclusions
Conditions
Response to coverage issues
Reservation of rights letter
Filing for declaratory judgment action

6. Claims Adjusting Process Liability
Sources of liability
Statutes
Contracts
Torts
Intentional
Negligence
Strict or absolute liability
Investigation of liability
Statements
Inspections
Document review

7. Claims Adjusting Process Damages
Property damage
Bodily injury damages
Medical
Loss of earnings
Pain and suffering
Consortium
(Sex, society and services)
Future damages
Punitive damages
Survival and wrongful death
Extra-contractual damages

8. Loss Reserving Case reserves Judgment Average value Tabular
IBNR (Incurred But Not Reported)
Reserving problems
Stair-stepping
Inconsistency

9. Claim Settlement Pre-settlement negotiation Persons involved Agent
Policyholder
Claimant
Witnesses
Attorneys
Negotiation of settlement
Denial of claims

10. Settlement Documents Proof of loss General release
Joint tortfeasor release
Covenant not to sue
High/low agreements
Release for injury to a minor
Parent’s release and indemnity agreement
Nominal releases
Release draft
Telephone recorded releases

11. Litigation Alternatives to litigation Arbitration Mediation
Rent-a-judge
Settlement conferences
Summary jury trials
Selection and direction of outside attorneys
Decisions relating to defense
Defend or settle
Nuisance settlements
Subrogation

12. Measuring Claim Performance
Financial measures
Loss ratio
Accuracy
Consistency
Claim-handling performance
Turnover of claims
Average cost of settlement
Litigation rates
Average caseload
Staff turnover