HI Claims Adjuster cheat sheet

HRS chapter 431 is the Hawaii Insurance Code; it is administered by the Insurance Division of the Department of Commerce and Consumer Affairs (DCCA), headed by the Insurance Commissioner.

Hawaii's motor vehicle insurance law (HRS 431:10C) requires minimum liability limits of $20,000 per person and $40,000 per accident for bodily injury, plus $10,000 for property damage.

Hawaii is a no-fault state: personal injury protection of at least $10,000 per person pays reasonable medical expenses and lost wages regardless of fault; tort recovery for non-economic loss is limited to serious injury or medical expenses above the statutory threshold.

Unfair trade practices and unfair claim settlement practices are codified at HRS 431:13-103; the Commissioner may investigate, issue cease-and-desist orders, and impose monetary penalties.

The Hawaii Prepaid Health Care Act (HRS chapter 393) requires employers to provide health coverage to employees working 20 or more hours per week, making Hawaii the only state with an employer health insurance mandate.

The Hawaii Insurance Guaranty Association (HRS chapter 431:16) pays covered property and casualty claims of insolvent insurers, subject to statutory per-claim caps; life and health claims fall under a separate guaranty association.

The Hawaii Property Insurance Association (HPIA) is the state's residual market, providing basic property coverage where the voluntary market is unavailable, including high-risk hurricane and lava zones.

Insurance fraud is a crime in Hawaii; motor vehicle insurance fraud is addressed specifically in HRS 431:10C-307.7, and the Insurance Division maintains a fraud investigation function.

Workers' compensation (HRS chapter 386) is a no-fault, exclusive-remedy system administered by the Disability Compensation Division of the Department of Labor and Industrial Relations.

Insurable interest must exist at policy inception for life insurance and at the time of loss for property insurance; without it the insured has no enforceable right to recover.

The principle of indemnity limits a property settlement to the insured's actual financial loss, so a claimant may not profit from a loss, though recovery is also capped by policy limits.

Actual cash value equals replacement cost minus depreciation; replacement cost coverage pays new-for-old value subject to policy limits and a duty to repair or replace within the stated period.

Coinsurance penalty formula: payment = (insurance carried / insurance required) x loss, where insurance required = coinsurance percentage x property value at the time of loss.

Insurance contracts are contracts of adhesion, aleatory and unilateral in nature, and conditional; they are governed by the doctrine of utmost good faith, which binds both parties.

Policy structure runs declarations, insuring agreement, conditions, exclusions, then endorsements; endorsements amend the printed form and control when the two conflict.

Subrogation gives the insurer the insured's right of recovery against a liable third party after payment; the insured must not impair that right, for example by signing a release.

An HO-3 insures the dwelling on an open-peril (special) basis but personal property on a named-peril basis; an HO-5 insures both on an open-peril basis; HO-4 covers renters and HO-6 covers condominium unit owners.

Other insurance clauses allocate loss by pro rata share of limits, by primary and excess order, or as excess only; a deductible is not shared with other insurers unless the clause says so.

The duty of good faith and fair dealing runs to the insured; a breach can support a bad-faith action and exposure beyond the policy limit.

Unfair claim practices typically include failure to acknowledge claim communications promptly, failure to conduct a reasonable investigation, and denial without a stated factual or policy basis.

A reservation of rights letter lets the insurer defend the insured while preserving coverage defenses; a non-waiver agreement accomplishes the same purpose and must be signed by the insured.

When a coverage dispute gives the insurer control of a defense that could establish facts defeating coverage, the insured may be entitled to independent counsel paid by the insurer.

The claim file should document the first notice date, every contact attempt, recorded statements or examinations under oath, photographs, estimates, reserve changes, and the basis for each coverage decision.

Written coverage position letters should identify the specific policy provisions relied upon, the facts supporting the position, and any additional information the insurer needs to complete its evaluation.

An examination under oath is a policy condition in many forms; unreasonable refusal to cooperate can bar the claim where the insurer is substantially prejudiced.

Claim files contain personal, medical and financial data protected by state privacy law and the Gramm-Leach-Bliley Act; disclosure is limited to need-to-know or insured-authorized recipients.

An adjuster may not give legal advice or represent an insurer without proper licensure by the Hawaii Insurance Division, and no fee or referral arrangement may compromise objectivity.

Confirm coverage first: policy form edition, endorsements, policy period, named insured, insured location, occupancy, and any mortgage or loss-payee clause.

Separate covered from excluded perils at the outset; when a covered and an excluded peril combine, apply the efficient proximate cause doctrine to the dominant, initiating cause.

Compute depreciation for actual cash value by age, condition and expected life; replacement cost settlements normally require repair or replacement within a stated time limit.

The deductible applies once per occurrence to the covered loss; percentage wind or hurricane deductibles are calculated against the dwelling limit rather than a flat dollar amount.

Ordinance or law coverage responds to the increased cost of repairing to current building code, which base dwelling coverage does not provide.

Flood, including storm surge, is excluded under standard homeowners forms and requires a separate flood policy; wind-driven rain is covered only when it enters through an opening created by wind.

The earth movement exclusion generally reaches volcanic action and lava flow, so Hawaii coverage for lava damage depends on the specific endorsement, HPIA form or surplus lines policy in force.

Business income pays lost net income plus continuing normal expenses during the period of restoration, and extra expense pays costs that let the insured resume operations sooner.

A proof of loss is a sworn statement itemizing amounts claimed, usually due within a set number of days after the insurer's request; failure to file can prejudice the claim.

Liability requires proof of duty, breach, causation and damages; the claimant bears the burden on each element in a third-party casualty claim.

Comparative negligence reduces a claimant's recovery in proportion to the claimant's own fault rather than barring the claim outright.

Damages are categorized as special (medical bills, lost wages, out-of-pocket expense) and general (pain and suffering); punitive damages require egregious conduct.

Automobile liability limits are written per person and per occurrence; defense costs are generally outside the limit for commercial general liability and inside the limit for personal auto liability.

An occurrence policy is triggered by injury during the policy period; a claims-made policy is triggered by the claim being made or reported during the period, subject to a retroactive date.

Uninsured and underinsured motorist coverage responds when the at-fault driver has no insurance or limits below the insured's damages; Hawaii requires insurers to offer it unless the insured rejects it in writing.

Medicare, Medicaid and hospital liens attach to third-party recoveries and must be identified and resolved before the release is signed and the file is closed.

Reservation of rights letters preserve coverage defenses while the liability investigation proceeds; a signed release and documented settlement authority are required before payment.

Subrogation requires early identification of liable third parties, preservation of evidence, and awareness of the statute of limitations on the underlying injury claim.