CIA Claims Investigation & Reporting Standards 3 — Questions and Answers
Question 1: An auto liability claim involves a claimant who alleges soft-tissue injuries. Which investigative tool is MOST useful for identifying pre-existing conditions?
- Recorded statement about the accident
- Independent Medical Examination (IME) and prior medical record review (Correct answer)
- Surveillance of the claimant's home
- Review of the claimant's social media posts only
Correct answer: Independent Medical Examination (IME) and prior medical record review
An IME combined with prior medical records directly identifies pre-existing conditions that may affect causation and damages.
Question 2: The concept of 'contributory negligence' in a liability claim investigation is important because it can:
- Increase the claimant's recovery in all US states
- Reduce or bar the claimant's recovery depending on state law (Correct answer)
- Only apply to product liability claims
- Eliminate the need for a coverage analysis
Correct answer: Reduce or bar the claimant's recovery depending on state law
Contributory or comparative negligence rules, which vary by state, can reduce or completely bar a claimant's recovery when they share fault.
Question 3: When preparing a claim investigation report, the adjuster should present findings in what manner?
- With editorial opinions about the claimant's character
- Objectively, based on facts gathered, with analysis tied to policy language (Correct answer)
- Summarizing only the evidence favorable to the insurer
- Using legal conclusions rather than factual findings
Correct answer: Objectively, based on facts gathered, with analysis tied to policy language
Investigation reports must be objective, fact-based, and directly tied to policy terms to support defensible claim decisions.
Question 4: A homeowner files a water damage claim but the adjuster suspects the damage pre-dates the policy period. The BEST investigative approach is to:
- Immediately deny based on suspicion
- Order a coverage inspection, review prior insurance history, and consult a moisture or construction expert (Correct answer)
- Accept the claim to avoid litigation
- Ask the insured to provide their own contractor estimate only
Correct answer: Order a coverage inspection, review prior insurance history, and consult a moisture or construction expert
Determining when damage occurred requires expert analysis, inspection history, and prior coverage records to establish a timeline.
Question 5: What is 'index bureau' data used for in claims investigation?
- Calculating property replacement values
- Identifying prior claims history across multiple insurers to detect patterns of fraud (Correct answer)
- Estimating bodily injury damages in a lawsuit
- Determining the applicable state statute of limitations
Correct answer: Identifying prior claims history across multiple insurers to detect patterns of fraud
Index bureau databases (such as ISO ClaimSearch) aggregate claims data across insurers to reveal suspicious patterns or prior losses.
Question 6: In a workers' compensation claim investigation, which document best establishes the causal link between the workplace incident and the claimed injury?
- The claimant's performance review
- The treating physician's report connecting the injury to the described workplace event (Correct answer)
- A co-worker's general character statement
- The employer's quarterly revenue report
Correct answer: The treating physician's report connecting the injury to the described workplace event
A treating physician's medical report establishing causation between the workplace incident and the diagnosed injury is the primary medical evidence.
Question 7: Which of the following is a recognized red flag for potential insurance fraud in a commercial property fire claim?
- The insured has multiple years of continuous coverage with no prior claims
- The insured recently increased coverage limits significantly and has financial difficulties (Correct answer)
- The fire department responded within minutes and contained the fire quickly
- The insured promptly filed a proof of loss
Correct answer: The insured recently increased coverage limits significantly and has financial difficulties
A recent significant coverage increase combined with the insured's financial distress is a classic fraud indicator in property fire claims.
CIA Claims Investigation & Reporting Standards 3
An auto liability claim involves a claimant who alleges soft-tissue injuries.
Which investigative tool is MOST useful for identifying pre-existing conditions?