MT Claims Adjuster flashcards

31 cards. Read the term and the definition here. The deck at the top of this page is optional.

Montana Commissioner of Insurance

State official who heads the Insurance and Securities Division, enforces Title 33 of the Montana Code, adopts administrative rules, and examines insurer market conduct and claim practices.

MCA 33-18-201

Montana's unfair trade practice statute; it lists prohibited claim practices including misrepresenting policy provisions and failing to attempt a prompt, fair settlement once liability is reasonably clear.

Third-party bad faith action

Under MCA 33-18-242, a claimant may sue an insurer directly for unfair claim practices when the insurer's violation is committed with actual malice or fraud, subject to a one-year limitations period.

Montana producer continuing education

Producers must complete 24 credit hours every two years, including at least three hours of ethics, under ARM 6.6.4401 et seq.; adjusters satisfy separate CE requirements under their own licensing rules.

Montana legislative effective date

Montana's legislature meets in odd-numbered years; unless a bill states otherwise, amendments to the Insurance Code take effect October 1 following passage, so adjusters must confirm the applicable version.

First-party claim acknowledgment

MCA 33-15-1103 requires the insurer to acknowledge a first-party claim within 15 business days and to accept or deny it within 30 business days after receiving proof of loss.

Montana administrative rules citation

Insurance Division regulations appear in the Administrative Rules of Montana, Title 6, Chapter 6, and implement statutes such as licensing, continuing education, and claim practice standards.

Adjuster licensing statute

MCA 33-17-101 et seq. governs adjuster licensing in Montana, including examination, appointment, and the requirement to handle claims in accordance with state law.

Fiduciary duty of adjuster

The adjuster must act in the insurer's interest while treating the insured fairly; this means accurate investigation, honest evaluation, and no self-dealing in the claim outcome.

Conflict of interest disclosure

An adjuster with a personal, family, or financial connection to a claimant or loss must disclose the conflict and be reassigned to preserve impartial claim handling.

Denial letter requirements

A written denial must identify the specific policy provision relied on, state the factual basis for the decision, and inform the insured of available remedies such as the Department of Insurance complaint process.

Claim file confidentiality

Medical records, financial data, and claim details may be disclosed only for legitimate claim handling or when required by law, subpoena, or the insured's authorization.

Balanced investigation

Ethical claim handling requires seeking evidence both supporting and defeating coverage; a one-sided investigation is a recognized indicator of bad faith.

Settlement authority limits

An adjuster may commit the insurer only within delegated authority; promising payment before coverage and damages are confirmed can bind the insurer and violates ethical practice.

Contemporaneous documentation

Recording contacts, statements, and decisions at the time they occur creates a defensible record for bad-faith litigation and Department of Insurance market conduct examinations.

Good faith and fair dealing

Implied covenant requiring the insurer and its adjuster to handle claims honestly and promptly, without unreasonable delay or pretextual reasons for denial.

Actual cash value formula

ACV equals replacement cost minus depreciation; it reflects the property's value at the time of loss rather than the cost to buy new equivalent property.

Replacement cost value

RCV pays the cost to repair or replace with new property of like kind and quality, without deduction for depreciation, subject to policy limits and any conditions such as repair completion.

Coinsurance recovery formula

Recovery equals limit carried divided by limit required, multiplied by the loss, capped at the policy limit; required limit equals coinsurance percentage times property value at loss.

Percentage deductible

A deductible stated as a percentage of the dwelling or building limit, common in wind and hail coverage, rather than a flat dollar amount applied to the loss.

Negligence four elements

A liability claim requires duty, breach of that duty, causation of harm, and actual damages; failure to prove any element defeats the claim.

Montana comparative negligence

Under MCA 27-1-702, damages are reduced in proportion to the claimant's fault, and a claimant more than 50 percent at fault recovers nothing.

Business income loss formula

Business income loss equals lost net income plus continuing normal operating expenses, minus noncontinuing expenses, for the period of restoration needed to repair or replace with due diligence.

Period of restoration

The time reasonably required to repair or replace damaged property with due diligence, beginning at the date of loss and ending when the property should be operational.

Subrogation right

After paying a loss, the insurer acquires the insured's right to recover from the responsible third party; the insured must not impair that right through release or settlement.

Vehicle total loss settlement

Payment equals actual cash value plus applicable taxes and fees, less the deductible and less salvage value if the insured retains the salvage vehicle.

Proof of loss

A sworn statement from the insured detailing the amount and cause of loss; the insurer's decision deadline under Montana law runs from receipt of this document.

Additional living expense

Coverage for increased costs of temporary housing and living incurred while the residence is uninhabitable due to a covered loss, usually limited by a time or dollar cap.

Salvage value

The amount a damaged item can be sold for in its damaged condition; it is deducted from the loss payment when the insured keeps the damaged property.

Occurrence vs. claims-made

An occurrence policy covers losses that happen during the policy period regardless of when claimed; a claims-made policy covers claims first made during the policy period.

Duty to defend

The insurer's obligation to provide a legal defense for covered claims, which is broader than the duty to indemnify and is triggered when allegations potentially fall within coverage.