Claims investigation, settlement negotiation, and adjuster ethics concepts tested on state insurance adjuster licensing exams.
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- What is the primary responsibility of an insurance adjuster?
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To investigate insurance claims fairly and determine coverage eligibility and benefit amounts.- Name the three main types of adjusters categorized by employment status.
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Staff adjusters (employed by insurer), independent adjusters (contract workers), and public adjusters (represent claimants).- What is the adjuster's duty of investigation?
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To conduct a thorough, prompt, and reasonably diligent investigation of all material facts relevant to the claim.- What is a deposition in the claims context?
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Sworn, out-of-court testimony recorded by a court reporter, used to preserve evidence or discovery.- Define subrogation in insurance.
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The right of an insurer to pursue a third party responsible for a loss to recover amounts paid to the insured.- What is the difference between first-party and third-party claims?
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First-party: the insured files against their own insurer. Third-party: someone else files against the insured's liability insurance.- What does the duty of good faith and fair dealing require of an adjuster?
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To act honestly, investigate thoroughly, communicate promptly, and not act in bad faith or with malice toward the claimant.- What is a conflict of interest in claims adjustment?
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A situation where an adjuster's personal financial interest or relationship could influence their claim decision or investigation.- When must an adjuster disclose information about a conflict of interest?
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Immediately upon discovery or when it becomes reasonably apparent, before continuing the claim investigation.- What is the purpose of an Independent Medical Examination (IME)?
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To have a neutral physician evaluate the claimant's injuries and medical treatment for accuracy and medical necessity.- What documents must an adjuster retain in a claim file?
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All investigation notes, photographs, medical records, repair estimates, correspondence, and settlement agreements.- How long must claim files typically be retained by an insurer?
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Generally three to six years from claim closure, or as required by state law.- What is a coverage investigation?
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An investigation to determine whether the policy covers the loss, including policy limits, exclusions, and conditions.- Define the duty to defend in liability insurance.
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The insurer's obligation to provide legal defense for the insured in covered claims, regardless of ultimate liability.- What is comparative negligence?
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A legal doctrine allowing liability and damages to be apportioned between parties based on their percentage of fault.
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