Adjusting staff are, upon training, very knowledgeable folks. The nature of claim adjusting exposes staff to a breadth of claim scenarios, damages, and inspection sites. While there is no ‘owner’s manual’ to which one can refer in investigating claims, there is the wealth of personal and team knowledge available to address most inspections.
Unfortunately, the depth of knowledge among adjusters is becoming less each day as tenured staff retire, and eager new staff replace those who have experience dealing with unique situations. Besides there not being an owner’s manual for claim handling, there are few who enter the insurance claim world with the breadth of experience one gains over years/decades of claim investigation. Doesn’t make them unqualified to do great work, just less aware of the many types of damage/circumstances that are claimed by customers.
What’s a claim adjuster to do when these unique situations come up? The customer needs claim resolution, the facts of loss or evidence of damage are outside of the adjuster’s knowledge. Maybe even outside of the knowledge of the claim manager. They can’t simply pay the claim, and the claim cannot be placed on indefinite pending status.
Engineers, fire investigators, hygienists, building scientists, and investigators add cost, add time to claim handling and in general take some of the control from the well-trained adjuster. Why not make your best call on the nature of the damage and the coverage determination?
Insurance policies are contracts of risk sharing between the carrier and the customer. Even the most well-written policy is weighted to the carrier’s understanding- the carrier’s staff works with the policy and its language every day, every claim. The expectations of the customer are typically addressed upon filing a claim, and often are in opposition to the language and intent of the policy. If every claim was paid to the customers’ expectations this discussion would be moot- no investigation, no need for clarity of policy application, no need to support adverse decisions in the customers’ eyes. Additionally, there are many circumstances that simply exceed the adjuster’s skills in understanding, or require statutory or regulatory involvement of experts.
Consider these reasons to use an expert in claim handling:
- The customer demands appraisal per policy provision. You need a disinterested, qualified party to represent the appraisal action.
- Hazardous materials or conditions are present or claimed by the insured. An assessor is needed due to the science needed or potentially due to local law or regulation.
- The scope of damage and cause exceeds the skill level of the adjuster.
- There is potential for subrogation or liability exposure; obtaining a highest and best skill assessment and conclusion supports the investigation.
- There is a denial of coverage, a disagreement between the parties and an independent third party will help with understanding by the parties.
- The scope of the loss is unique; the adjuster’s available tools to determine repair method and/or repair estimate are not adequate to the circumstance.
- Risk analysis finds the claim may proceed to litigation; use of an expert now will support defense actions if legal action occurs.
- Customer request- there are occasions where a customer simply needs to be reassured that the adjuster’s assessment is comprehensive. This is typical when an insured has an estimate/scope from a contractor or repair shop, and there is scope or cost differences.
- Helps support an environment of uniform and fair claims practices.
- The carrier is served a summons and complaint, or is notified that the insured has retained counsel.
- Use of outside counsel produces a diverse assessment/opinion than that of house counsel.
- An expert will provide a conclusion that is typically mated with empirical investigation of the damage and loss facts, and this will in addition to supporting the claim’s resolution serve as an education to staff.
These are a few of many reasons why an adjuster would be wise to contact an expert, with the recognition that cost and competency is considered. Every claim needs to be fully and uniformly investigated, and policy language applied similarly. Having the discretion and empowerment to use experts is an important option in all claim handling.
And, as tenured staff departs and less experienced staff come on board, an expert can help bridge the knowledge gap until staff are more seasoned. Experts will even help train- teach them to fish, as it were.