CCP Claims Investigation & Evaluation 2 — Questions and Answers
Question 1: When a claimant refuses to submit to an Examination Under Oath (EUO), what is the most likely consequence under a standard property policy?
- The insurer must pay the claim immediately
- Coverage may be voided due to breach of policy conditions (Correct answer)
- The insurer must obtain a court order before proceeding
- The claim is automatically referred to arbitration
Correct answer: Coverage may be voided due to breach of policy conditions
Most property policies require the insured to submit to an EUO as a condition of coverage, and refusal can constitute a material breach that voids the claim.
Question 2: A claims adjuster discovers that the date of loss reported by the insured does not align with weather records. What is the best next step?
- Close the claim as fraudulent immediately
- Obtain certified weather data and request clarification from the insured (Correct answer)
- Pay the claim to avoid bad faith exposure
- Refer the case to the SIU without further investigation
Correct answer: Obtain certified weather data and request clarification from the insured
The adjuster should document objective weather records and give the insured an opportunity to explain the discrepancy before drawing conclusions.
Question 3: Which document is most useful when investigating whether a business income claim loss amount is accurate?
- The insured's social media posts
- The insured's prior-year tax returns and financial statements (Correct answer)
- Competitor revenue filings
- The policy's declarations page only
Correct answer: The insured's prior-year tax returns and financial statements
Tax returns and financial statements provide objective historical revenue data needed to project the business income loss during the interruption period.
Question 4: In a liability claim, what does 'proximate cause' mean?
- The nearest physical location to the accident
- The direct and efficient cause most closely linked to the loss (Correct answer)
- The last party to arrive at the scene
- The cause identified by the plaintiff's attorney
Correct answer: The direct and efficient cause most closely linked to the loss
Proximate cause is the primary cause that sets in motion the chain of events leading to the loss, determining legal liability.
Question 5: A recorded statement is best obtained from a claimant:
- Only after the claim has been denied
- As early as possible in the investigation while details are fresh (Correct answer)
- After the insured has retained an attorney
- Only if the claim exceeds the policy deductible by 50%
Correct answer: As early as possible in the investigation while details are fresh
Early recorded statements capture details before memories fade and before parties may be influenced by counsel or other parties.
Question 6: When evaluating a soft-tissue injury claim with no objective medical findings, an adjuster should:
- Automatically deny the claim as fraudulent
- Evaluate the claim based on subjective complaints, treatment records, and credibility factors (Correct answer)
- Pay policy limits without investigation
- Require the claimant to undergo surgery before evaluating
Correct answer: Evaluate the claim based on subjective complaints, treatment records, and credibility factors
Soft-tissue claims require holistic evaluation of subjective complaints, consistency with the mechanism of injury, treatment history, and overall credibility.
Question 7: What is the primary purpose of an Independent Medical Examination (IME) in a claims investigation?
- To replace the claimant's treating physician permanently
- To obtain an objective medical opinion on injury causation, extent, or treatment necessity (Correct answer)
- To deny all future medical payments automatically
- To satisfy state licensing requirements for the adjuster
Correct answer: To obtain an objective medical opinion on injury causation, extent, or treatment necessity
An IME provides an independent, objective medical assessment that helps evaluate causation, appropriateness of treatment, and degree of impairment.
CCP Claims Investigation & Evaluation 2
When a claimant refuses to submit to an Examination Under Oath (EUO), what is the most likely consequence under a standard property policy?