CAIA Bodily Injury Claim Evaluation 3 — Questions and Answers
Question 1: A claimant involved in a minor fender-bender with minimal vehicle damage claims severe back injuries. What investigative tool might an adjuster use to assess claim credibility?
- Request a vehicle odometer inspection
- Order an independent medical examination (IME) (Correct answer)
- Require the claimant to retake their driver's license test
- Conduct a property damage appraisal only
Correct answer: Order an independent medical examination (IME)
An IME provides an objective medical opinion on injury causation and severity when the claim appears disproportionate to the accident facts.
Question 2: Under a comparative negligence system, a claimant is found 30% at fault for an accident. If total damages are $50,000, what is the maximum bodily injury recovery?
- $50,000
- $35,000 (Correct answer)
- $15,000
- $0 because the claimant is partially at fault
Correct answer: $35,000
In a comparative negligence state, the claimant's recovery is reduced by their percentage of fault: $50,000 × 70% = $35,000.
Question 3: What is the significance of a 'reservation of rights' letter in a bodily injury claim?
- It confirms the insurer accepts full liability for the claim
- It notifies the insured that the insurer is investigating coverage while preserving its right to deny coverage later (Correct answer)
- It authorizes the claimant to seek immediate medical care at the insurer's expense
- It closes the claim pending litigation
Correct answer: It notifies the insured that the insurer is investigating coverage while preserving its right to deny coverage later
A reservation of rights letter protects the insurer's ability to deny coverage while still conducting a defense or investigation.
Question 4: Which document is the MOST important for evaluating a claimant's lost wage claim following an auto accident injury?
- The claimant's homeowner's insurance policy
- Employer verification letter and pay stubs showing pre-accident earnings (Correct answer)
- The police accident report narrative
- The vehicle title showing ownership
Correct answer: Employer verification letter and pay stubs showing pre-accident earnings
Lost wage claims require documentation of pre-accident earnings and employer confirmation of missed work days to establish the economic loss.
Question 5: A claimant treats exclusively with a chiropractor for six months following a minor accident. What concern might an adjuster have about this treatment pattern?
- Chiropractic care is never compensable under auto insurance
- Prolonged chiropractic treatment without medical physician oversight may indicate over-treatment (Correct answer)
- The claim must be denied because a chiropractor is not a licensed provider
- The adjuster should automatically double the settlement value
Correct answer: Prolonged chiropractic treatment without medical physician oversight may indicate over-treatment
Lengthy chiropractic treatment without medical physician supervision can signal over-treatment or soft tissue claim padding, affecting claim valuation.
Question 6: What is 'future medical expense' in bodily injury claims, and who typically establishes it?
- Costs already billed for emergency room treatment, established by billing records
- Anticipated ongoing medical costs beyond settlement, typically established by a treating physician or life care planner (Correct answer)
- The insurer's estimate of repair costs for future accidents
- Future premiums the claimant will pay due to accident history
Correct answer: Anticipated ongoing medical costs beyond settlement, typically established by a treating physician or life care planner
Future medical expenses are projected costs for ongoing treatment, often supported by a physician's prognosis or a formal life care plan.
Question 7: When a claimant presents both medical bills and a pain diary as evidence, what does the pain diary primarily support?
- The amount of property damage sustained
- General damages, specifically the nature and duration of pain and suffering (Correct answer)
- The claimant's insurance coverage limits
- The at-fault driver's liability percentage
Correct answer: General damages, specifically the nature and duration of pain and suffering
A pain diary documents daily impact on the claimant's life, directly supporting the general damages calculation for pain and suffering.
CAIA Bodily Injury Claim Evaluation 3
A claimant involved in a minor fender-bender with minimal vehicle damage claims severe back injuries.
What investigative tool might an adjuster use to assess claim credibility?