NM Claims Adjuster flashcards

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

New Mexico OSI

The Office of Superintendent of Insurance is the state agency that licenses insurers and adjusters, reviews rates and forms, handles consumer complaints, and enforces the Insurance Code.

Superintendent of Insurance

The official appointed by the Governor to lead OSI, with authority to examine insurers, issue orders, impose penalties, and revoke licenses for violations.

Independent adjuster

A licensed adjuster who contracts with insurers to handle claims for a fee, representing the insurer rather than the policyholder in the adjustment.

Public adjuster

A licensed adjuster who contracts with and is paid by the policyholder to prepare and negotiate a claim, and cannot represent the insurer on that claim.

NMSA Chapter 59A

The New Mexico Insurance Code, which contains licensing, rate and form filing, trade practice, and enforcement provisions governing insurers and adjusters in the state.

Unfair trade practice

A defined violation of the Insurance Code, such as misrepresentation, unfair discrimination, or unfair claim settlement, subject to OSI penalties and restitution orders.

Continuing education requirement

OSI-approved credit hours an adjuster must complete each renewal cycle, including ethics and state law topics, with records retained for audit.

Surplus lines placement

Insurance obtained from an unauthorized insurer through a licensed surplus lines broker when coverage is unavailable from admitted carriers in the voluntary market.

Unfair claim settlement

A practice such as misrepresenting policy terms, failing to investigate, delaying payment without cause, or denying a claim without a reasonable basis.

Prompt acknowledgment

The requirement that an insurer respond to a claimant's communication about a claim within the statutory period and begin investigation without unreasonable delay.

Written denial

A claim denial that identifies the specific policy provision and the factual basis relied on, so the claimant can understand and challenge the decision.

Claim file documentation

Contemporaneous records of contacts, investigation steps, estimates, payments, and denial reasons that support the claim decision in complaints and market-conduct exams.

OSI consumer complaint

A filed complaint that triggers an insurer response to the Superintendent within a set deadline, explaining the claim handling and the basis for the position.

Good-faith settlement evaluation

An offer based on reasonable investigation of liability and damages; an unreasonably low offer made without investigation can violate unfair practice rules.

Appraisal clause

A policy dispute process in which each party selects an appraiser and an umpire resolves valuation differences when coverage is agreed but amount is disputed.

Prompt payment rule

Once a settlement is agreed, the insurer must pay within the statutory period; unreasonable delay may trigger interest and penalties.

Coverage A through D

Homeowners limits for the dwelling, other structures, personal property, and loss of use, each stated separately in the declarations.

Replacement cost

The amount needed to repair or replace damaged property with new material of like kind and quality, without deduction for depreciation.

Actual cash value

Replacement cost minus depreciation, reflecting the value of the property at the time of loss rather than the cost of new materials.

Coinsurance formula

Payment equals insurance carried divided by insurance required, multiplied by the loss, capped at the policy limit; underinsurance reduces partial-loss recovery.

Percentage deductible

A deductible stated as a percentage of the dwelling limit, common for wind or hail, rather than a flat dollar amount.

Business income coverage

Pays lost net income plus continuing operating expenses during the period of restoration after a covered direct physical loss.

Liability trigger

Liability coverage responds to an occurrence or accident and is evaluated through duty, breach, causation, and damages, then limited by policy terms.

Uninsured motorist coverage

Coverage that pays the insured's damages when an at-fault driver has no liability insurance; New Mexico requires the coverage be offered.

Ensuing loss provision

A clause that restores coverage for a resulting loss from a specified peril even when the initiating cause is excluded.

Proof of loss

A sworn statement from the insured detailing the amount and cause of loss, required by the policy as a condition of payment.

Examination under oath

A policy condition allowing the insurer to question the insured under oath about the loss; unexcused refusal can bar recovery when the insurer is prejudiced.

Insurance fraud

Knowingly presenting a false claim, concealing material facts, or staging a loss to obtain payment, subject to criminal and civil remedies.

OSI Fraud Bureau

The unit that investigates suspected insurance fraud and refers cases to prosecutors, working with insurer anti-fraud reporting.

Fraud red flags

Indicators such as a loss soon after inception, prior claims, inflated or duplicate estimates, and inconsistent statements about time and cause.

Material misrepresentation

A false statement on an application that affects the insurer's decision to issue or rate the policy, allowing rescission or denial when relied upon.

Anti-fraud plan

An insurer's required procedures to detect, investigate, and report fraudulent claims, including staff training and documentation of referrals.

Origin and cause investigation

A documented analysis of where and how a fire or loss began, eliminating accidental causes and identifying intentional acts by a qualified investigator.