A general overview of the adjusting function. For most of us, it will be a refresher, but it will be very useful for people new to the business.

Handling Individual Claims Files

  • Immediate acknowledgement
  • Understand the coverage involved. Keep coverage in mind during the life of the claim.
  • 24-hour contact (or attempted contact) with parties involved in the claim
  • On-time reporting (7 to 14 days, depending upon client’s desires)
  • Outline at the beginning of the report the extent of the assignment
  • Appropriate aggressive follow-up until claim is concluded, or a passive approach is required
  • Timely follow-up reporting
  • Clear and proper evaluation and presentation of claim details to the client
  • Proper file documentation throughout (whether using a paper file, or an imaged file)
  • Appropriate storage of records in accordance with CPLIC guidelines
  • Prompt closing and billing when file is concluded
  • Proper dairy

TPA Programs

The above items are applicable to TPA programs.  However, there are many more items that adjusters handling TPA programs must keep in mind.

  • You are generally reporting to someone who is not a claims professional.  This places a high duty upon you to adjust, evaluate, and document the file properly.
  • Maintain good accounting reports
  • Provide detail reporting from risk management information systems on a regular basis.
  • Report to excess carriers as soon as a case approaches the carrier’s guidelines for reporting.
  • Those guidelines vary by excess carrier. This must be clearly documented in the file.
  • Identify and request subrogation as soon as it is obvious.
  • For workers’ compensation, understand second injury fund requirements, and comply with them promptly.

Diary

  • All claims organizations should have accountability through diary systems.