AMF Claims Adjuster (Quebec) key terms

Person who investigates a claim, determines whether coverage applies, quantifies the loss, and negotiates or recommends settlement. In Quebec the activity is regulated, and the adjuster owes duties of impartiality and good faith to both insurer and insured.

Obligation to deal honestly and fairly with the insured throughout claims handling, including explaining rights, avoiding misleading statements, and not using delay or technicalities to defeat a legitimate claim. It flows from the Civil Code and the insurance contract itself.

Situation where the adjuster's personal or financial interests, or a relationship with a party, could bias the claim decision. The adjuster must disclose and avoid such situations, since independence is essential to impartial claim handling.

Adjuster retained by an insurer on a contract basis rather than employed directly by it. The independent adjuster still owes the same professional duties and must remain impartial, even though the insurer pays the fee.

The insurer's core contractual obligation to compensate the insured for covered loss, up to the policy limits, once the claim is established. Payment must be made within the period set by law after proof of loss is received.

A financial or legal stake in the property or liability insured, such that the insured suffers real prejudice if the loss occurs. Without it, the insurance contract is generally unenforceable because it would resemble a wager.

The rule that property insurance restores the insured to the financial position held before the loss, without profit. It underpins actual cash value, replacement cost limits, and the prohibition on over-insurance and double recovery.

Risk that insurance protection may reduce the insured's incentive to prevent loss or may encourage exaggeration or fraud. Insurers address it through deductibles, warranties, investigation, and claims screening.

Principle that both parties to an insurance contract must disclose material facts fully and honestly. The insured must answer application questions truthfully; the insurer must disclose coverage terms and handle claims fairly.

A false or misleading statement by the insured during application or claims handling. If it is material and induced the insurer to issue or maintain coverage, it may justify reduction of indemnity or avoidance of the contract under the Civil Code.

A claim knowingly based on false facts, staged loss, or deliberate exaggeration, made to obtain an indemnity not owed. It can lead to denial of the claim, rescission, and criminal or civil consequences for the claimant.

The insured's formal statement, supported by documents, describing the circumstances of the loss, the damaged property, and the amount claimed. It triggers the insurer's obligation to decide and pay within the legal time limit.

Systematic process of gathering facts after a loss: statements, scene inspection, photographs, expert reports, financial records, and police or fire reports. Its purpose is to establish the cause, the extent of damage, and whether coverage applies.

The event or physical mechanism that produced the damage, such as fire, water escape, wind, or theft. Identifying the true cause is essential to determine whether a listed or all-risks coverage responds.

Coverage that responds to any cause of loss except those expressly excluded in the policy. The insured must show the loss occurred; the insurer bears the burden of proving an exclusion applies.

Coverage limited to the causes of loss specifically listed in the policy, such as fire, lightning, explosion, or windstorm. The insured generally has the burden of proving the loss resulted from a listed peril.

A policy provision removing specified losses or circumstances from coverage, such as intentional acts, wear and tear, or certain water damage. Exclusions are interpreted narrowly, and the insurer must prove their application.

The obligation of a party to establish a fact in dispute. In claims, the insured generally proves a covered loss occurred, while the insurer must prove any exclusion, condition breach, or misrepresentation it relies on.

Situation where a covered and an excluded cause contribute to the same loss. Courts must determine whether coverage applies, often by asking which cause was dominant or whether the excluded peril was a necessary element.

Indemnity measure equal to replacement cost less depreciation, reflecting the property's depreciated value at the time of loss. It is the default measure in many Quebec property policies unless replacement cost is expressly provided.

Cost to repair or rebuild with new materials of like kind and quality, without depreciation deduction. Coverage is usually subject to a limit and may require actual repair or replacement before the full amount is paid.

The maximum amount the insurer will pay for a covered loss under a given coverage. Sub-limits may apply to specific property or perils, and aggregate limits may cap total payments during the policy period.

The amount of each loss the insured must bear before the insurer pays. It is subtracted from the indemnity and may vary by peril; some policies apply a separate deductible for wind or earthquake.

Provision requiring the insured to carry insurance equal to a stated percentage of property value, failing which the indemnity is reduced proportionally. It penalizes under-insurance and is common in commercial property policies.

Improvement in the insured's position resulting from repairs or replacement with newer or superior materials. Adjusters deduct betterment so the indemnity does not exceed the actual loss.

Reduction in value of property due to age, wear, use, or obsolescence. It is the key deduction when calculating actual cash value and must be supported by evidence rather than guesswork.

The insurer's right, after paying a claim, to step into the insured's shoes and pursue recovery from the party responsible for the loss. It prevents double recovery and allocates loss to the at-fault party.

Statutory and contractual entitlement allowing the insurer to bring action against the third party who caused the loss, up to the amount paid. The insured must not prejudice this right, for example by releasing the responsible party.

Coverage protecting the insured against legal liability to others for bodily injury or property damage caused by the insured's fault. It also imposes a duty on the insurer to defend covered claims.

Under the Civil Code of Québec, the obligation to repair harm caused to another by one's fault, including imprudence, negligence, or lack of skill. It is the legal foundation of liability insurance in Quebec.

Conduct falling short of the standard of a reasonable person in the circumstances, including acts, omissions, and professional errors. Fault is the first element the claimant must prove in a civil liability action.

The required connection between the fault and the harm suffered. The claimant must show the injury would not have occurred but for the fault, or that the fault was a direct and determining cause of the damage.

The monetary amount awarded or negotiated to compensate bodily injury, property damage, or economic loss. Adjusters assess both special damages, such as repair invoices, and general damages, such as pain and suffering.

The insurer's obligation to provide and pay for legal counsel when the insured is sued for a claim potentially covered by the policy. It is broader than the duty to indemnify and arises even if coverage is doubtful.

Written notice by the insurer that it will defend or investigate a claim while reserving the right to deny coverage later. It protects the insurer from waiver and informs the insured of the potential coverage dispute.

Voluntary relinquishment of a known right, such as an insurer's right to rely on a breach of condition. It may arise from conduct or delay and can prevent the insurer from later denying coverage.

Rule preventing a party from asserting a right inconsistently with its earlier conduct on which the other party relied to its detriment. In insurance, it can bar an insurer from denying coverage after leading the insured to believe it existed.

The time within which a legal action must be brought or a claim asserted. In Quebec, insurance claims are subject to short statutory prescription periods, and adjusters must track deadlines carefully to avoid prejudice.