NY Claims Adjuster flashcards

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

Principle of indemnity

The insured is restored to approximately the same financial position held immediately before the loss, no better and no worse, so an insurance recovery cannot create profit.

Insurable interest

A financial stake in the insured person or property such that a loss causes genuine economic harm; for property coverage it must exist at the time of loss.

Contract of adhesion

A policy drafted solely by the insurer and accepted or rejected by the insured as written; ambiguities are construed against the insurer under contra proferentem.

Subrogation right

After paying a covered loss, the insurer acquires the insured's right to recover from the responsible third party, which prevents the insured from collecting twice.

Regulation 64

11 NYCRR 216, New York's unfair claim settlement practices regulation, which sets standards and timeframes for acknowledging, investigating, and resolving first- and third-party claims.

Insurance Law section 2601

The New York statute listing unfair claim settlement practices, including failing to act promptly on communications and refusing to pay without a reasonable investigation.

Fire policy suit limitation

New York's standard fire policy bars a lawsuit on the claim unless it is filed within 24 months after inception of the loss.

No-fault thirty-day filing

A New York no-fault claimant must file the application for benefits within 30 days of the accident, and the insurer must pay or deny within 30 days of receiving proof.

New York auto minimum limits

Compulsory liability coverage of at least $25,000 per person and $50,000 per accident for bodily injury and $10,000 for property damage.

Coverage B other structures

On a homeowners policy, structures detached from the dwelling are insured for a limit equal to 10% of the Coverage A amount unless another limit is shown.

Coverage D loss of use

Pays additional living expenses and lost fair rental value while the dwelling is uninhabitable, typically limited to 30% of the Coverage A amount.

Mortgagee clause

Provisions giving the lender the right to receive loss payments and to remain protected even when the insured's acts or neglect would otherwise impair coverage.

Appraisal provision

A method for resolving disagreements about the amount of loss: each side selects a competent appraiser and the two appraisers choose an umpire.

Actual cash value

Replacement cost of the damaged property less depreciation, reflecting its value in the condition it was in immediately before the loss occurred.

Duty to defend

Broader than the duty to indemnify; it is triggered by any claim potentially within coverage, even allegations that are groundless, false, or fraudulent.

Claims-made policy

Responds to claims first made and reported during the policy period, limited by a retroactive date and extended by optional reporting period endorsements.

Serious injury threshold

New York no-fault rule requiring a tort claimant to prove an injury meeting one of the statutory categories of Insurance Law section 5102(d).

Supplementary uninsured motorist coverage

New York coverage that must be offered and pays an insured for damages caused by an uninsured or underinsured motorist, subject to stated limits.

Pure comparative negligence

Under CPLR 1411, a claimant's recovery is reduced by his or her own percentage of fault, and recovery is permitted even at 99% fault.

Reservation of rights letter

Written notice that the insurer will investigate or defend the claim while reserving the right to deny coverage later, preserving defenses that might otherwise be waived.

Examination under oath

A sworn, recorded questioning of the insured conducted during the investigation where the policy requires it; unjustified refusal can bar the claim.

Sworn proof of loss

A signed statement detailing the date, cause, and amount of loss with supporting documentation, usually due within 60 days of the insurer's request.

Subrogation preservation

Identifying third-party responsibility early, giving notice to those parties, and avoiding any release that would extinguish the insurer's recovery rights.

Medicare Secondary Payer

Federal rule making Medicare secondary to other coverage; liability settlements must address Medicare conditional payments and, where applicable, future medical costs through a set-aside.

General release

A settlement document in which the claimant gives up all claims arising from the incident against the released parties in exchange for stated consideration.

Special versus general damages

Special damages are documented economic losses such as medical bills and lost wages; general damages compensate non-economic harms such as pain and suffering.

BATNA

The best alternative to a negotiated agreement, which fixes the point at which a party walks away rather than accept the terms on the table.

Expected value reserving

An estimate of claim exposure calculated as the probability of an adverse outcome multiplied by the likely severity, plus defense and adjustment expense.

Unfair claim practice

Under Insurance Law section 2601, conduct such as misrepresenting policy provisions, failing to investigate, or refusing to pay without a reasonable explanation.

Fiduciary claim funds

Settlement drafts and trust monies must be held for the payee's benefit and disbursed promptly; commingling with the adjuster's or insurer's funds is prohibited.

Conflict of interest

A personal, financial, or family interest in a claim that must be disclosed and that disqualifies the adjuster from handling the matter impartially.

Claim record retention

New York requires insurers to keep claim and business records for at least six years under 11 NYCRR 243, Regulation 152.