Documentation & Reporting Flashcards

An adjuster records a file note stating the claimant 'seemed like a liar.' What is the main problem with this entry?

Answer: It is a subjective opinion that could be damaging if the file is discovered in litigation

Claim file notes should be factual and objective because the file may be discoverable in bad-faith or coverage litigation.

Under the NAIC Unfair Claims Settlement Practices model regulation, an insurer generally must acknowledge receipt of a claim notice within how many days?

Answer: 15 days

The NAIC model regulation generally requires acknowledgment within 15 calendar days, though individual states may vary.

Which item best documents the insurer's reasoning when it sets or changes a reserve on a claim?

Answer: A file note explaining the facts and evaluation that support the reserve amount

Reserve changes should be supported by a documented rationale based on current facts and evaluation.

Before taking a recorded statement by phone, what should the adjuster capture at the start of the recording?

Answer: The witness's consent to record, identity, date, and time

A proper recorded statement opens by identifying the parties, date and time, and confirming consent to be recorded.

A diary (suspense) system in claim handling is primarily used to:

Answer: Schedule follow-up reviews so required actions are taken on time

Diary systems flag files for timely follow-up, helping prevent missed deadlines and unfair delays.

When an insurer denies a claim, best practice and most state regulations require the denial to be:

Answer: In writing, citing the specific policy provisions relied upon

Unfair claims practices laws generally require a written denial that references the specific policy language or facts relied on.

Photographs taken at a loss scene are most useful as documentation when they:

Answer: Are dated and labeled with location, subject, and who took them

Labeled, unaltered, dated photos establish authenticity and context for the evidence.