(This information came from Mike Cerf (prairielaw forum))
Once Again, The Inside Game
12/10/99
I thought I might take a moment to comment on the "inside game" What you must realize is that behind the walls of the claims office it is another world. When you have a claim never for a moment reach the conclusion that your interests are first and foremost in the minds of the claims department of most carriers.
For example, adjusters speak with each other when PIP and Liability is involved. Lets just take the case where the PIP carrier is Screen Door Mutual and the Liability Carrier, is No Pay Mutual. What occurs is that the liability adjuster will call the PIP carrier and say, "look you have subrogation you need to collect and I do not want to face over treatment" or the adjuster might say, " if you do not control the PIP we will deny your subrogation."
Mike's Rule: The carrier in the majority of cases looks to their own interest first.
The inside game serves several functions, first in the long run it lowers exposure on the liability side, the liability adjuster gets the PIP adjuster to get an early IME, this will serve two functions the first being it lowers his liability exposure and lowers his PIP subrogation pay out. By the way, the adjuster just may suggest the IME provider to use, they know who will bring in the results in balance, not always, but most of the time you get a good IME, that is one that reduces your exposure. This works best on soft tissue cases, noting that if you really have an injury the IME will not be all that good for the carriers.
The inside game serves several functions, first in the long run it lowers exposure on the liability side, the liability adjuster gets the PIP adjuster to get an early IME, this will serve two functions the first being it lowers his liability exposure and lowers his PIP subrogation pay out. By the way, the adjuster just may suggest the IME provider to use, they know who will bring in the results in balance, not always, but most of the time you get a good IME, that is one that reduces your exposure. This works best on soft tissue cases, noting that if you really have an injury the IME will not be all that good for the carriers.
Mike's Rule: There is nothing independent about IME's.
Now think about this it also lowers the PIP adjusters exposure, so in the long run on the entire book of business all benefit. If you are running a PIP book (that is total open claim reserves) of say $10M and you can reduce PIP 10%, that is $1M, think about that as only a small example. Then flip the same result to the liability side but a much larger number, say $30M and you save 10%.
Now think about this it also lowers the PIP adjusters exposure, so in the long run on the entire book of business all benefit. If you are running a PIP book (that is total open claim reserves) of say $10M and you can reduce PIP 10%, that is $1M, think about that as only a small example. Then flip the same result to the liability side but a much larger number, say $30M and you save 10%.
Mike's Rule: Small percentages on large numbers equate to large profits
Do not fool yourself, adjusters talk with each other and you can count on the third party adjuster knowing a lot about your clients claim, the PIP adjuster will in most cases tell him, amount of medical, wage loss, who they are treating with and general nature of injury and if they did an IME what the results are, this does not occur in all cases but in occurs very often.
Do not fool yourself, adjusters talk with each other and you can count on the third party adjuster knowing a lot about your clients claim, the PIP adjuster will in most cases tell him, amount of medical, wage loss, who they are treating with and general nature of injury and if they did an IME what the results are, this does not occur in all cases but in occurs very often.
Mike's Rule: Adjusters have common interests that are not equal to yours
The real problem occurs when the same carrier has the PIP and the liability. You must never kid yourself, information can and in some cases is shared when it should not be. This does not occur with all carriers but with many it does. The key is you must not let this occur, demand the files be split to different offices and send letters to both putting them on notice that you as an individual or attorney will not (1) authorize the PIP carrier in any form to communicate with the liability adjuster regarding the injury, keep in mind they will communicate about the amount of bills (2) demand the liability adjuster not communicate with the PIP adjuster to obtain medical or wage information without your written consent.
The real problem occurs when the same carrier has the PIP and the liability. You must never kid yourself, information can and in some cases is shared when it should not be. This does not occur with all carriers but with many it does. The key is you must not let this occur, demand the files be split to different offices and send letters to both putting them on notice that you as an individual or attorney will not (1) authorize the PIP carrier in any form to communicate with the liability adjuster regarding the injury, keep in mind they will communicate about the amount of bills (2) demand the liability adjuster not communicate with the PIP adjuster to obtain medical or wage information without your written consent.
Mike's Rule: Do not expect your claim to be confidential
One of the key elements you must know is that the liability adjuster will demand an early IME if he or she sees the case in terms of treatment going south. The call is made and there is your IME. Now if one carrier has both sides, be very careful about an IME, it serves the interest of the carrier and not you as a third party claimant, insured or counsel. The IME then becomes a legal question where if you do not have counsel you might just want to get one before you consent. If your are the attorney watch out.
One of the key elements you must know is that the liability adjuster will demand an early IME if he or she sees the case in terms of treatment going south. The call is made and there is your IME. Now if one carrier has both sides, be very careful about an IME, it serves the interest of the carrier and not you as a third party claimant, insured or counsel. The IME then becomes a legal question where if you do not have counsel you might just want to get one before you consent. If your are the attorney watch out.
Mike's Rule : The process is not about fairness or equity
Do not blame the adjuster he or she did exactly what is in their performance objectives. Look to management and how they have set forth claims procedures and guidelines and set performance goals, bottom line there is very little independent or fair about the matter, it is not about justice, truth or equity it is all about bottom line dollars, and the name of the game is reduce exposure.
Bottom line: Do not create the expectation that you will get what you think you deserve, you will get what the adjuster thinks you deserve. Is that right, no it is not, but that is the real world of claims.
Mike Cerf
Expert Witness Insurance Claims
Sherwood, Oregon
mcerf@teleport.com
Truth and Justice will prevail! Promote it for all you are worth, or your worth will be nothing!
PR CRAP!Please don't believe "You're in Good Hands", or that "A Good Neighbor" will deliver "A Piece Of The Rock", if you buy their Insurance!
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