Claims Processing & Investigation Flashcards
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Read the first 7 Claims Processing & Investigation flashcards as text
Which factor is MOST critical when establishing the 'proximate cause' of a loss in claims investigation?
Answer: The dominant, efficient cause that set the chain of events in motion
Proximate cause is the primary, unbroken cause that directly produced the loss, not merely the final act in a sequence.
A 'non-waiver agreement' signed during a claim investigation serves to:
Answer: Allow the insurer to investigate without waiving any policy defenses
Like a reservation of rights letter, a non-waiver agreement protects the insurer's coverage defenses while allowing claim investigation to proceed.
In an automobile liability claim, 'medical payments coverage' (MedPay) differs from bodily injury liability because it:
Answer: Pays regardless of fault for medical expenses to the insured and passengers
MedPay is a no-fault first-party coverage that pays medical expenses for the insured and passengers without regard to who caused the accident.
When using the 'Actual Cash Value' (ACV) method to settle a property claim, adjusters must account for:
Answer: Replacement cost minus physical depreciation
ACV equals replacement cost minus depreciation, reflecting the item's fair market value at the time of loss.
An 'Examination Under Oath' (EUO) in insurance claims differs from a recorded statement because it is:
Answer: A formal legal proceeding with sworn testimony and often a court reporter
An EUO is a formal contractual right where the insured testifies under oath before a court reporter, creating a legal record that can be used in coverage disputes.
In fraud detection, 'link analysis' during claims investigation is used to:
Answer: Identify relationships between claimants, providers, or attorneys suggesting organized fraud rings
Link analysis maps connections between people, entities, and claims to reveal patterns indicative of coordinated insurance fraud schemes.
The 'statute of limitations' in claims handling refers to:
Answer: The legal deadline by which a claimant must file a lawsuit against the insurer
The statute of limitations is the legally set time window within which a claimant must initiate legal action or lose the right to sue.