Claims Handling Practices and Procedures
The regulated workflow
A defensible claim file tells a chronological story. Open the file with the date and time of first notice, the identity and authority of the caller, the policy number and date of loss, and a coverage confirmation or reservation of rights. Under Regulation 64, send a written acknowledgment with the necessary forms and instructions within 15 business days, give the claimant a claim number and contact, and respond in writing to communications within 15 business days.
Then build the record: coverage analysis tied to policy language, a documented investigation plan, contact logs, photographs, recorded statements, expert reports, and a reserve rationale. Issue written status letters at meaningful intervals and never let a file go silent. Any denial must be in writing, cite the specific policy provision relied on, and explain the factual basis; if coverage is uncertain, use a reservation of rights rather than an outright denial. For liability claims, a disclaimer must go out as soon as reasonably possible under §3420(d).
Pay promptly once the amount is agreed - first-party property payment after proof of loss, third-party payment after a signed release and lien clearance - and document the closing letter.
Traps: treating a reservation of rights as a disclaimer (it is not); using an unlicensed adjuster; demanding documents the insured does not have to produce; missing the acknowledgment clock because the file sat unassigned; failing to explain a reduction in value; and omitting the insured's right to contact the Department of Financial Services.
Rule of thumb: if a file has had no diary entry in 15 business days, it needs a letter or a documented action - silence is the most common unfair-practice finding.