Claims Adjustment Fundamentals and the Adjuster's Role
The adjuster's function
An adjuster's job is to investigate a claim, determine whether coverage exists, quantify the loss, and settle or recommend settlement. In Quebec, the adjuster is a regulated professional acting under provincial licensing rules, and is expected to act in good faith toward both insurer and insured. Distinguish the adjuster from the broker (who places coverage) and the underwriter (who accepts risk).
The investigation cycle
A disciplined sequence is: acknowledge the claim promptly, verify the policy and its declarations, establish the cause and date of loss, confirm the insured interest and identity, gather documentary evidence (photos, invoices, police or fire reports), then quantify the indemnity and document the file. Each step must be recorded, because file notes are the adjuster's evidence of diligence.
Core concepts to master
- Coverage before quantum: never negotiate an amount before confirming that the peril, the property, and the person are covered.
- Burden of proof: the insured generally proves the loss occurred and falls within coverage; the insurer asserting an exclusion usually bears that burden.
- Indemnity principle: the insured should be restored, not enriched.
- Subrogation: after paying, the insurer may step into the insured's rights against a third party.
- Conflicts of interest and the duty to disclose them.
Traps in questions
Questions often blur the roles of adjuster, broker, and underwriter, or ask who bears the burden on an exclusion. Another trap is treating a friendly conversation with the insured as a binding admission of coverage.
Rule of thumb
Apply a "four-gate" test before any payment: Is the peril covered? Is the property covered? Is the person/interest covered? Is the amount documented? If any gate fails, stop and investigate further.