Structure and Mission, Chapter
1, 12/13/99
I thought I would do some musings on the inside game from start to finish, that is
once your claim or your clients claim hits the desk of the claims rep. what happens, just
how is the inside game played out against you or your client.
Mike's Primary Rule: It is not about fairness, truth or
equity, it is all about money, nothing more nothing less.
The first thing you need to understand is the internal structure of a typical claims unit,
this relates to how your case or your clients case is assigned.
Typical Unit Structure are broken down as to classes of business and function within
classes of business.
Typical Unit Structure:
1. Auto
2. General Liability
3. Property - this being real property, your homeowners claims
4. PIP (Personal Injury Protection) and Med-Pay
5. Clerical Unit
Where Auto Claims Go:
1. Fast Track - claims that can be moved in 21 to 30 days or less are held in this unit
and those claims without injury and no attorney representation
2. BI unit - claims that have injury and/or attorney representation
3. Litigation unit - handles claims when they go into litigation
4. Complex or Major Claims unit - handles claims with serious injury, i.e., burns,
amputations, death, etc. and value at reserve is over $150,000. Also handles complex
coverage issues.
5. PIP Unit and Med Pay.
Supporting those units:
Appraisers - Some carriers will have attached to the auto unit appraisers that run drive
in claims offices and come to look at your car at the shop or your home.
Outside adjusters - Attached to the units and supporting all of the units will be field
adjusters who work outside, do scene investigations, come to the home , track down outside
information.
SIU (Special Investigation Unit) - this is where red flag cases go, i.e. suspected fraud.
Clerical - Handles all of the paper processing and issues checks, etc.
When a case comes into a claims office it comes in as follows:
1. Accord - this is a standard industry form, that the agent completes and faxes or mails
to the claims office.
2. Insured - calls the claims office direct & reports the loss.
3. Claimant - calls the office and reports the loss, now in some claims offices the try
and take the position they will not accept a report from a claimant, that should be
resisted and reported on to the claims manager, they will take the claim.
4. Attorney - calls and reports the claims.
5. Other carriers - calls and reports the claim.
When the case is reported it is then sorted along the lines of the unit structure and
assigned by a supervisor to an adjuster with basic instructions on what to do or in
some cases just assigned with no instructions.
Now the claim is on your adjusters desk:
1. Reserve is established at set up or within 21 days, or the computer sets a factor
reserve which is just an average reserve depending on the claims of damage that must be
changed in 21 days.
2. Contact - 24 hour contact is the rule, contact the claimant in 24 hours this helps
control the case, i.e., they do not get into the hands of the dark side (plaintiff
attorney) to soon.
3. PD - assigns appraiser to look and photo car, now the purpose is two fold, one to get
the PD out of the way and second the photos to determine if you or your client could have
been hurt in the claim, get photos all four sides of car and three of point of impact is
the general rule and measurements of height of point of impact in some cases.
4. RS or Recorded Statement, get it on first contact from claimant, this helps refute
claims of injury and least in minds of adjuster.
5. First call settlement authority, try and dump the case over the phone on first call if
they complain of just a little injury and project out treatment if needed, now all
carriers allow first call settlements but some limit the amount, but an adjuster who is
good at first calls, is on their way up the organization.
6. Get medical and wage authorization.
This gets you though the opening of the claim or the first 24 hours after it hits the
desk, next musing will take you through the next part of the inside game, getting your PD
claim settled.
BACK TO MENU
CHAPTER
2
Mike Cerf
Expert Witness Insurance Claims
Sherwood, Oregon
503-925-1937
mcerf@teleport.com
Truth and Justice will prevail!
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