Excellence in Claims Handling Now Available on Substack

he first publication is a fictionalized true crime story about insurance fraud called “The Great Jewel Theft” that is the first of more than 80 true crime stories that will be published on Substack as well as digests of new insurance law appellate decisions.

Introduction to Excellence In Claims Handling

In search of profit, insurers have decimated their professional claims staff. They laid off experienced personnel and replaced them with young, untrained, unprepared people. A virtual clerk replaced the old professional claims handler. Process and computers replaced hands-on human skill and judgment. Money was saved by paying lower salaries. Within three months of firing the experienced claims people gross profit increased.A site for the insurance claims professional and anyone who wants to know something about insurance, insurance claims, insurance coverage, and insurance law.

Insurance claims professionals are people who:
• can read and understand the insurance policies issued by the insurer.
• understand the promises made by the policy and their obligation, as an insurer’s claims staff, to fulfill the promises made.
• are competent investigators.
• have empathy, and recognize the difference between empathy and sympathy.
• understand medicine relating to traumatic injuries and are sufficiently versed in tort law to deal with lawyers as equals.
• understand how to repair damage to real and personal property and the value of the repairs or the property.
An insurer whose claims staff is made up of people who are less than professional will find itself the subject of multiple instances of expensive, counterproductive litigation.

The excellence in claims handling program requires thorough training providing each member of the claims staff with a minimum of the following:
1. How to read and understand the contract that is the basis of every adjustment, including but not limited to:
a. The formation of the insurance policy.
b. The rules of interpretation.
2. Tort law including negligence, strict liability in tort, and intentional torts.
3. Contract law including the insurance contract, the commercial or residential lease agreement, the bill of lading, nonwaiver agreements, proofs of loss, releases and other claims related contracts.
a. The duties and obligations of the insured in a personal injury claim.
b. The duties and obligations of the insurer in a personal injury claim.
c. The duties and obligations of the insured in a first party property claim.
d. The duties and obligations of the insurer in a first party property claim.
4. The Fair Claims Practices Act and the regulations that enforce it.
5. The thorough investigation:
a. Basic investigation of an auto accident claim.
b. Investigation of a construction defect claim.
c. Investigation of a nonauto negligence claim.
d. Investigation of a strict liability claim.
e. Investigation of the first party property claim.
f. The recorded statement of the first party property claimant.
g. The recorded statement or interview of a third party claimant.
h. The recorded statement of the insured.
i. The red flags of fraud.
j. The SIU and the obligation of the claims representative when fraud is suspected.
6. Claims report writing.
7. The evaluation and settlement of the personal injury claim.
8. How to retain coverage counsel to aid when a coverage issue is detected.
a. How to control coverage counsel.
b. How to instruct coverage counsel on the issue to be resolved.
9. Dealing with a plaintiff’s lawyer.
10. Dealing with personal injury defense counsel.
11. The evaluation and settlement of the property damage claim.
12. The Appraisal process.
13. Arbitration and mediation and the claims representative.

Claims handling without excellence is both dangerous and expensive. Insurers should develop a professional claims staff and provide excellence in claims handling because by so doing they will profit more than if they keep an inadequate and unprofessional claims staff.

The series of videos will be available soon for a monthly subscription. The video here is a tease to the beginning of the courses which will run approximately one hour each.

Barry Zalma, Esq., CFE

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 54 years in the insurance business. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual Claims Magazine/ACE Legend Award.