(This information came from Mike Cerf (prairielaw forum))
"Statements and the Adjuster"
11/16/1999
I wanted to take a moment to provide a
musing regarding how a typical auto case gets worked up. Recently there have been many
postings about not giving the adjuster access to your client for a statement, so I thought
it might be of interest to provide a brief profile of how an auto case moves through the
maze.
Adjusters have case books or investigation guidelines that in general we expect them to
follow in order to ensure that key questions are asked in each and every case, granted in
most cases they have to add some questions to fit the particulars but most statements are
set guidelines. These statements are reviewed and graded and become part of the
adjusters performance review, note not all statements are reviewed
General note on how a claim file is graded by an audit team, noting I spent a long time on
one of these teams
1. Investigation
2. Coverage
3. Procedure
4. Evaluation
5. Disposition - Or settlement
6. Litigation management if applicable
7. Recovery
How it all works from the claims side in a typical auto case:
Typical Auto Case
1. Statement will cover (recorded) (noting this is best you can always play it back in
court for impeachment), basic details about date, time and place; weather conditions,
lighting conditions; street conditions; did you have your lights on; any recent car
maintenance; where were you coming from and going to; purpose of trip; what time did
your start; where did you stop; describe street you were on, first saw part of statement,
i.e., when did you first see car, this is terms of feet away or car lengths; how fast were
you going, what is the speed limits, are you familiar with area, what did you do, i.e.,
apply brakes, etc.; where did impact occur (location on street) and where is damage to
your car and other car; where did cars end up (coming to rest scene); did you observe any
skid marks, what did other party say; witness who are they; complaints of injury; did you
go to doctor, what doctor, miss any work, what do you make, how much time did you miss,
any prior accidents or injury, prior workers compensation claims, did police come; who was
cited; many more questions can be asked but this is a general guideline.
2. scene diagram and photos will be done
3. photos of cars and four sides and three of point of impact
4. witness canvass at scene
5. interview police officer
6. if applicable interview tow truck driver, ambulance driver, para-medics
7. if possible always a first call settlement offer, assuming minor complaints, even if
they have a doctor or PT that states three months of treatment, how much is projected, we
will give you that plus $500 to $1,000 here is your check
8. Get medical authorization and wage right up front
9. Index completed on your client for index bureau
10. If there are SIU ( Special Investigation Unit) flags, NICB is ran (National Insurance
Crimes Bureau)
11. Gather medical and wage information-- If low speed/low velocity impact, most likely
you will draw a medical in house review with a med-service and/or a expert team up front
as well as SIU review in some cases. Also if you have two clients and you represent both
and they are treating with the same doctor or DC you most likely will draw SIU review and
a medical profile from an outside service
12. Call other carrier or write them if they have PIP that they should do early IME if
required to control medical as reasonable and necessary, or just call them and tell them
look, this treatment is questionable will you do an IME, this is then a dual benefit for
both carriers and done all of the time.
13. Request authority within your reserve
14. Try and settle, if you cannot, it makes little difference if the case goes to
litigation does not increase overall pay out a lot in most cases that are soft tissue,
costs plaintiff a lot more than the carrier. Keep in mind if there is a real dispute over
liability and or nature and extent of injury that carrier has every right to dispute your
demand. But this dispute must be based on the reality of the case, not a biased
perception.
A biased perception is created at the time authority is requested when, you have a case
with minor PD, treatment with a DC, treatment over 90 days, subjective complaints no real
objective findings, Doctors notes indicated your firm referred them to the doctor or DC,
extended time off from work for minor soft tissue injury. Treatment is massage, plus pt
and DC manipulation.
Keep in mind that in the majority of auto cases 80% of them the loss dollar exposure is
under $100,000 in most books of business, the rule being that 20% of your losses driver
80% of your large loss dollar cases, and in most books that is cases greater than
$100,000.
Immediate assignment to defense counsel will be made on heavy exposures, those where your
exposure is over $250,000 or you have treaty reinsurance reporting, but questionable
liability. This way it is all work product. Done all the time. Assign reconstruction and
other experts up front, and do it quick, the old saying is, "I got Mine."
Treaty reinsurance claims are when the carrier can lay off a part of the risk to a rein
surer, for example, you have a $1,000,000 policy, the primary carrier, the carrier for the
defendant accepts, 60% to 80% of the risk, and lay of say 40% to the rein surer. This
requires on even questionable or a no liability case for a alert to be sent to the
reinsurer, these are claims for: Death, loss of a limb, para or quad, loss of eye, aids,
high profile individual, public interest law firm, class actions suits, very bad
disfigurement.
All in all keep in mind the adjuster has a job to do, he has the money and you for your
client need to get the adjuster to pay you a reasonable value for the claim, but the
process for you to get that money is more or less engraved in stone, but keep in mind it
is not a must for the adjuster to have a statement in his file for you to get paid. If you
send him a statement signed by your client that in most cases will suffice, or just send
him a standard accident report and tell him that is all you are going to get
All are correct you ask for a statement from the insured you will get none, and by the way
it is rather standard operating procedure that the adjuster will tell the insured on the
phone and at times in writing, "Speak to no person but me about this accident, if you
get contacted give them my name and claim number." This is most often the drill
the minute the loss is reported even before the adjuster gets the report.
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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