Claims Analysis Guidelines
One important rule in adjusting claims is that each claim must be reviewed, the facts investigated and the claim adjusted on the merits of the individual claim. The proper resolution of each individual claim must be viewed on its own merits. The unique merits of each claim notwithstanding, there are general standards and guidelines that exist for proper claims handling.
When I am asked to analyze and evaluate another claim person(s) claim handling to determine whether a claim was handled in conformance with all the insurer’s obligations under the insurance contract, the implied covenant of good faith and fair dealing, statutory law and accepted claims industry standards, there are numerous factors I consider. The factors include, but are not limited to, the following:
|• Prompt & Continuing Contact with the Insured & Their
Representatives during Investigation
• Thorough Investigation of the Claim
• Applicable Statutory Law, & the Individual Facts of
• Payment or Denial of Payment on a Partial or Entire Basis
Is in Accordance with Applicable Policy
Terms & Conditions
|• Proper Internal File Reporting & Involvement of Claim
Supervisory Personnel in the Investigation &
• The Retention of Proper Experts as Required by Each
• Continual Documentation of the Results of Investigatory
In Good Faith
Following these claim-handling activities are necessary to produce a fair and equitable analysis on a specific claim. This process when followed ensures that the review of the claim handling is properly and reasonably analyzed. If a claim is handled fairly, equitably, and properly under the facts and circumstances presented, then such a claim is within the custom & practice of the industry.