CCA Claims Handling and Investigation 2 — Questions and Answers
Question 1: When a claimant reports a loss, what is the adjuster's FIRST priority?
- Deny the claim if coverage is unclear
- Acknowledge receipt and set expectations for the process (Correct answer)
- Request a recorded statement immediately
- Dispatch an independent appraiser
Correct answer: Acknowledge receipt and set expectations for the process
Prompt acknowledgment and communication of next steps is a best practice and often a regulatory requirement to initiate good-faith handling.
Question 2: Which document grants an adjuster the legal authority to act on behalf of an insurer in settling claims?
- Proof of Loss form
- Power of Attorney
- Letter of Authorization (Correct answer)
- Claims Assignment Order
Correct answer: Letter of Authorization
A Letter of Authorization (or similar delegation letter) formally grants the adjuster authority to act on the insurer's behalf in a specific claim.
Question 3: A claimant submits a sworn Proof of Loss 65 days after a fire loss, but the policy requires submission within 60 days. What should the adjuster consider?
- Automatically deny the claim for late submission
- Waive the requirement if the insurer's conduct did not prejudice the claimant (Correct answer)
- Accept it without any review
- Request a new Proof of Loss with a falsified date
Correct answer: Waive the requirement if the insurer's conduct did not prejudice the claimant
Courts often find that an insurer waives a late Proof of Loss deadline if its own conduct (e.g., ongoing negotiations) prevented timely submission or caused no prejudice.
Question 4: What is the primary purpose of an Examination Under Oath (EUO) in a claims investigation?
- To replace the Proof of Loss requirement
- To allow the insurer to gather sworn testimony about the loss (Correct answer)
- To provide mediation between insurer and claimant
- To settle the claim without litigation
Correct answer: To allow the insurer to gather sworn testimony about the loss
An EUO is a contractual right that allows the insurer to question the insured under oath to fully investigate the facts and circumstances of a claim.
Question 5: An insured's home is burglarized and personal property is stolen. The insured cannot produce original receipts. What is the BEST approach for the adjuster?
- Deny the claim due to lack of documentation
- Accept only items with receipts
- Use alternative documentation such as credit card statements, photos, or owner's manuals (Correct answer)
- Pay a flat settlement without itemizing
Correct answer: Use alternative documentation such as credit card statements, photos, or owner's manuals
Adjusters should work with claimants to gather alternative evidence of ownership and value when original receipts are unavailable.
Question 6: In a liability claim, what does 'subrogation' allow the insurer to do after paying a claim?
- Rescind the insured's policy
- Pursue the responsible third party to recover amounts paid (Correct answer)
- Deny future claims from the same insured
- Increase the insured's premium retroactively
Correct answer: Pursue the responsible third party to recover amounts paid
Subrogation allows the insurer to step into the insured's shoes and seek recovery from the negligent third party who caused the loss.
Question 7: When investigating a workers' compensation claim, which factor is MOST important to establish compensability?
- The employer's size and payroll
- Whether the injury arose out of and in the course of employment (Correct answer)
- The employee's years of service
- Whether the employee has prior claims history
Correct answer: Whether the injury arose out of and in the course of employment
Workers' compensation covers injuries that both 'arise out of' (caused by work) and occur 'in the course of' (during work) employment.
CCA Claims Handling and Investigation 2
When a claimant reports a loss, what is the adjuster's FIRST priority?