CAIA Bodily Injury Claim Evaluation 5 — Questions and Answers
Question 1: A claimant settles a bodily injury claim and signs a release. Three months later, they discover a more serious injury from the same accident. What is the typical legal outcome?
- They can reopen the claim because the injury was discovered after settlement
- The signed release generally bars recovery for subsequently discovered injuries from the same accident (Correct answer)
- The insurer must pay additional damages automatically
- They may file a new claim under the other driver's property damage coverage
Correct answer: The signed release generally bars recovery for subsequently discovered injuries from the same accident
A general release typically extinguishes all claims arising from the accident, including injuries discovered after signing, which is why claimants should ensure full recovery before settling.
Question 2: What does 'maximum medical improvement' (MMI) mean, and why is it important in bodily injury claim timing?
- The claimant has recovered 100% to pre-accident condition
- The claimant's condition has stabilized and further significant recovery is not expected, making it the ideal time to evaluate final damages (Correct answer)
- The treating physician has billed the maximum allowable amount
- The claimant has reached the policy's medical payment limit
Correct answer: The claimant's condition has stabilized and further significant recovery is not expected, making it the ideal time to evaluate final damages
MMI marks the point where treatment has achieved its maximum benefit, allowing adjusters to accurately assess total past and future medical needs for final settlement.
Question 3: An adjuster discovers through social media that a claimant claiming severe mobility limitations is playing recreational basketball. How can this information be used?
- It cannot be used because social media is private information
- It can be used as evidence to challenge the credibility and severity of the claimed injuries during claim evaluation (Correct answer)
- It automatically results in a criminal fraud referral
- It must be ignored unless the claimant submits it voluntarily
Correct answer: It can be used as evidence to challenge the credibility and severity of the claimed injuries during claim evaluation
Publicly available social media posts showing activities inconsistent with claimed injuries are legitimate evidence that can be used to challenge damage claims.
Question 4: When a claimant has health insurance that paid their accident-related medical bills, what is the insurer's potential obligation regarding those payments?
- None—the health insurer already paid, so no further obligation exists
- The bodily injury settlement may need to account for the health insurer's subrogation lien against the recovery (Correct answer)
- The health insurer's payments must be excluded from the damages calculation entirely
- The claimant can collect both from the health insurer and the BI insurer with no offset
Correct answer: The bodily injury settlement may need to account for the health insurer's subrogation lien against the recovery
Health insurers often assert subrogation liens, requiring repayment from the BI settlement, which the adjuster must factor into evaluating the claimant's net recovery.
Question 5: A claimant is self-employed and claims $15,000 in lost income due to accident injuries. What documentation should the adjuster require?
- A personal statement from the claimant is sufficient
- Tax returns, business financial records, and documentation showing income loss during the disability period (Correct answer)
- Only a letter from the claimant's bank confirming account balance changes
- A signed affidavit from the claimant's spouse
Correct answer: Tax returns, business financial records, and documentation showing income loss during the disability period
Self-employed claimants must provide tax returns and business records to objectively establish actual income loss, since no employer can verify wages.
Question 6: What role does a 'life care plan' play in evaluating a catastrophic bodily injury claim?
- It establishes the at-fault driver's insurance coverage limits
- It provides a detailed projection of all future medical, rehabilitation, and personal care costs for a severely injured claimant (Correct answer)
- It calculates the claimant's current medical bills only
- It determines the statutory limit for pain and suffering in the claimant's state
Correct answer: It provides a detailed projection of all future medical, rehabilitation, and personal care costs for a severely injured claimant
A life care plan, prepared by a qualified professional, projects lifelong medical and support costs, forming the foundation for future damages in catastrophic injury cases.
Question 7: A bodily injury claim is approaching the statute of limitations deadline but no settlement has been reached. What action might the claimant take to preserve their rights?
- Request an extension of the policy limits
- File a lawsuit before the statute of limitations expires to preserve their legal right to pursue damages (Correct answer)
- Submit a new insurance claim under a different policy
- Demand arbitration only through the insurance company
Correct answer: File a lawsuit before the statute of limitations expires to preserve their legal right to pursue damages
Filing a lawsuit before the statute of limitations expires preserves the claimant's right to seek damages even if settlement negotiations are ongoing.
CAIA Bodily Injury Claim Evaluation 5
A claimant settles a bodily injury claim and signs a release.
Three months later, they discover a more serious injury from the same accident.
What is the typical legal outcome?