NY Claims Adjuster cheat sheet

Principle of indemnity: after a loss the insured is restored to approximately the same financial position held before the loss - never better; insureds cannot profit from insurance.

Insurable interest must exist at the time of loss for property insurance; for life insurance it must exist at policy inception.

A policy is a contract of adhesion drafted by the insurer, so ambiguities are construed against the insurer (contra proferentem) in favor of the insured.

Subrogation: after paying the loss the insurer stands in the insured's shoes and can pursue the responsible third party, preventing double recovery by the insured.

Utmost good faith: a material misrepresentation or concealment on the application can support rescission of the policy or denial of the claim.

Proximate cause is an unbroken chain of events between the peril and the loss; anti-concurrent causation clauses exclude losses where an excluded peril contributes, regardless of order.

Loss sharing devices that leave part of the loss with the insured include deductibles, coinsurance clauses, and policy limits - all are applied before payment.

Waiver is the voluntary relinquishment of a known right; estoppel bars the insurer from asserting a right after the insured reasonably and detrimentally relied on the insurer's conduct.

11 NYCRR 216 (Regulation 64) governs claim handling: written acknowledgment of a claim notification is required within 15 business days, and claim forms must be furnished within 15 business days.

Regulation 64 requires the insurer to pay or deny a claim within 30 business days after receiving a complete proof of loss, with written notice if more time is needed.

Insurance Law §2601 defines unfair claim settlement practices, including failure to acknowledge or act promptly on communications and refusal to pay without a reasonable investigation.

New York's standard fire policy contains a 24-month suit limitation and requires a sworn proof of loss; the 24-month period runs from inception of the loss.

Insurance Law §3425 restricts cancellation and nonrenewal of personal lines policies and requires advance written notice, with a 10-day notice period for cancellation for nonpayment of premium.

Insurance Law §3426 governs commercial lines: 45 days' notice for cancellation for reasons other than nonpayment and 10 days' notice for nonpayment.

Minimum New York auto liability limits are $25,000 per person and $50,000 per accident for bodily injury and $10,000 for property damage.

No-fault (PIP) provides a minimum of $50,000 per person; the application for benefits is due within 30 days of the accident and the insurer must pay or deny within 30 days of receiving proof.

Insurance Law §5102(d) sets the serious injury threshold that must be met before a no-fault claimant may sue for non-economic damages in tort.

Homeowners HO-3 insures the dwelling on a special (open peril) basis while personal property is insured for broad named perils.

Standard HO limits: Coverage B other structures 10% of Coverage A; Coverage C personal property 50% of Coverage A; Coverage D loss of use 30% of Coverage A.

Coverage D pays additional living expenses and fair rental value for the shortest time needed to repair, relocate, or for the policy period stated.

Loss settlement: actual cash value is paid until repair or replacement is completed, at which point the withheld depreciation may be released under replacement cost coverage.

Coinsurance formula: (insurance carried / insurance required) x loss = recovery, then reduced to the policy limit if lower; the percentage (commonly 80%) applies to the property's value at the time of loss.

The mortgagee clause gives the lender an independent right to receive loss payments and continues its protection even when the insured's acts would otherwise void coverage.

Appraisal resolves disputes over the amount of loss only: each party selects a competent appraiser and the appraisers select an umpire; coverage disputes are not appraisable.

Common property exclusions: flood, earth movement, ordinance or law (with limited additional coverage), neglect, intentional loss, and vacancy or unoccupancy conditions.

Additional coverages include debris removal, trees and shrubs, collapse, and credit card or forgery coverage, each with its own sub-limit.

Commercial general liability Coverage A covers bodily injury and property damage; Coverage B covers personal and advertising injury; Coverage C provides medical payments.

The duty to defend is broader than the duty to indemnify and is triggered whenever the allegations potentially fall within coverage, even if the suit is groundless, false, or fraudulent.

Occurrence policies respond to injury or damage that takes place during the policy period; claims-made policies respond to claims first made and reported during the period, bounded by the retroactive date.

Extended reporting period (tail) coverage extends the reporting window after a claims-made policy expires but does not extend the retroactive date.

Additional insured status arises only from a policy provision or endorsement; a certificate of insurance is evidence of coverage, not a grant of coverage.

Supplementary uninsured/underinsured motorist coverage must be offered in New York and pays when an uninsured or underinsured motorist causes injury; minimum limits mirror the 25/50 liability limits.

New York follows pure comparative negligence (CPLR 1411), reducing a claimant's recovery by his or her percentage of fault regardless of how great that percentage is.

Workers' compensation is the exclusive remedy against the employer, barring a tort suit by the injured worker except for intentional torts.

New York Labor Law §§240 and 241(6) impose non-delegable liability on owners and contractors for elevation-related and construction site injuries.

First notice of loss intake captures date and time of loss, location, cause, parties, witnesses, and reported damages, and triggers coverage verification against the declarations.

Written acknowledgment must be sent within 15 business days of claim notification under Regulation 64, identifying the claim number and the assigned representative.

A reservation of rights letter or non-waiver agreement preserves the insurer's coverage defenses while investigation and defense continue.

A sworn proof of loss is typically due within 60 days of the insurer's request; an examination under oath may be required where the policy provides for it.

Every contact, decision, reserve change, and payment must be documented contemporaneously; the claim file is the primary evidence of compliance and good faith.

Evidence must be preserved early: scene photographs, witness statements, physical evidence, and recorded statements, with attention to spoliation exposure.

Subrogation should be identified at intake, third parties put on notice, and the applicable statute of limitations diarized before any release is signed.

Suspected fraudulent claims are referred to the New York State Department of Financial Services Insurance Frauds Bureau; accusations are never made without documented evidence.

Claimant personal information is protected data under 23 NYCRR 500 (cybersecurity) and may be used only for legitimate claim purposes.

Evaluate three separate questions in sequence: coverage, liability, and damages; a weakness in any one changes the settlement value.

Damage categories: special (documented economic loss such as medical bills and lost earnings) versus general (non-economic harms such as pain and suffering).

Expected value reserving: estimated exposure = probability of an adverse outcome x likely severity, plus allocated loss adjustment and defense expense.

New York statutes of limitation: three years for personal injury (CPLR 214), six years for breach of contract, two years for suit under a fire policy.

Liens must be identified and resolved before disbursement: Medicare conditional payments, Medicaid, workers' compensation, and hospital liens.

Medicare Secondary Payer rules require consideration of conditional payments already made and, where applicable, a Medicare Set-Aside for future medical costs in the settlement.

Releases must match the deal: a general release extinguishes all claims arising from the incident, while a limited or partial release preserves specified claims or parties.

BATNA (best alternative to a negotiated agreement) sets the walk-away point; the reservation price and settlement authority define the range within which an adjuster may move.

New York generally has no first-party bad faith tort; an injured third party may sue the liability insurer directly under Insurance Law §3420 only after obtaining a judgment against the insured.

Insurance Law §2601 prohibits misrepresenting policy provisions, failing to acknowledge claim communications with reasonable promptness, and refusing to pay without a reasonable investigation.

Regulation 64 enumerates prohibited practices, including failure to explain the basis for denial, failure to conduct a prompt investigation, and offering substantially less than the amount ultimately recovered.

Once liability and damages are reasonably clear, the insurer must attempt a prompt, fair, and equitable settlement; compelling litigation by low offers is an unfair practice.

Adjusters may not threaten criminal prosecution, immigration consequences, or other unrelated harm to obtain a settlement or a statement.

Settlement funds are held in trust for the payee and must be disbursed promptly; commingling claim funds with operating funds is prohibited.

An adjuster must disclose any personal, financial, or family interest in a claim and must decline the assignment where impartial judgment could be compromised.

Claimant information is confidential and may be disclosed only as needed to investigate, evaluate, or resolve the claim, or as required by law.

Insurers must retain claim and business records for at least six years under 11 NYCRR 243 (Regulation 152), and must respond promptly and completely to DFS inquiries.