Claims Handling and Adjustment Practices
Claims Handling and Adjustment Practices
This domain tests the practical sequence: investigate, document, communicate, quantify, negotiate, and close-while avoiding bad-faith conduct.
Core rules
- Acknowledge the claim, investigate promptly, and request only information reasonably needed.
- Document the loss with photos, measurements, moisture readings, expert reports, and a dated claim diary.
- Prepare a scope and estimate using consistent pricing; compare the insurer’s estimate line by line.
- Explain policy provisions and the insured’s duties; obtain a signed proof of loss when required.
- Negotiate in writing when possible; never settle without authority and informed consent.
- If agreement fails, use policy remedies such as appraisal or, when appropriate, legal referral.
Worked example
A burst-pipe claim shows water in a ceiling. The insurer’s adjuster proposes to pay for drywall only. The public adjuster inspects, finds saturated insulation and mold growth, and obtains a moisture report. The policy covers sudden pipe discharge but excludes long-term seepage. Because the pipe burst on a specific date and the mold is a consequence of the covered water, the adjuster documents the causal chain and seeks coverage for insulation and remediation while excluding pre-existing seepage. The claim file shows reasoning, not just a demand.
Traps
- Accepting the insurer’s scope without independent measurement.
- Delaying notice or proof of loss until coverage is jeopardized.
- Making oral settlement promises without written confirmation.
- Failing to separate covered sudden damage from excluded long-term deterioration.