|Sweet Claims Company has developed a set of Best Practices as a road map to success. These practices are the principals used in managing the claims process and as a guide in our comprehensive claims management strategy.
The Best Practices are not a by the numbers method of handling each claim. Claim adjusters utilize their expertise to determine what task is necessary to resolve each claim on its own merits. The Best Practices represent the minimum standards used to resolve each claim in the most timely and effective manner possible.
Our success in properly managing claims and enhancing our position in the industry is dependent upon our adherence to these practices.
A superior product contains work of the highest quality and is consistent from office to office, file to file and adjuster to adjuster. In order to achieve this uniformity and foster confidence from our clients, the following procedures will be followed in all cases.
Incoming mail and faxes must be date stamped on the date received. Mail containing multiple pages must be stamped on the first page and the last page.
First reports must be reviewed, reserved and processed into our claim system within 7 business days of receipt by a claims office.
All file material including the first report must be fastened to the inside right of the file jacket. All file material must be in chronological order. Discard all duplicate file material. Multiple volume claim files should be numbered.
All open claim files must be on diary. Diary dates must be realistic to the circumstances of each claim. A comment must be placed in your activity log documenting the review of the file corresponding to the diary date.
The most important aspect of a properly managed claim file is communication. Communication starts with Initial Contact. Prompt contact solidifies our plan of being responsive to all parties involved and locks in the facts of the situation while they are fresh in peoples minds.
Voice to voice contact with the client or insured must be made within 24 hours of receipt of the claim in the office.
Voice to voice contact must be made with the claimant within 24 hours of receipt of the claim in the office.
Voice to voice contact with claimant attorney must be made within 24 hours of the notice of representation. Acknowledgement (not agreement) of an attorney lien letter must be in writing and mailed within 3business days.
Good Faith Attempts
Good faith attempts to contact the applicable party within the specified time frame must be made. If voice to voice contact is not made, an accounting of the efforts and explanation must be documented in the adjuster activity log. At the end of 24 hours, if voice to voice contact has not been made, a letter must be sent and contact will be considered made. However, voice to voice contact must still be made.
The backbone of a claims file is the investigation. Without a quality investigation it is unlikely the assessment of liability will be accurate or the reserves will reflect a clear view of the exposure to the insured.
Statements are the frameworks by which we coordinate our investigations and lock in the facts of the claim. Recorded statements or signed statements are acceptable. Signed statements are the method of choice. We believe it is beneficial for an investigator to have some face to face interaction with the claimant/insured to determine his or her abilities as a witness as well as to get a feel for the validity of the individual story.
Claimant statements are to be taken on each claim where bodily/personal injury is alleged.
Client statements are to be taken when necessary. The client/insured version of an incident where a statement is not necessary should be documented in the adjuster activity log as reflected during the initial 24-hour contact.
Witness statements are to be taken on any claim where witness testimony is material to determining liability or damages. Witness statement forms can be used in all other situations.
Summaries of all statements should be documented in the adjuster activity log. If for any reason a statement is not taken it should be explained in the adjuster activity log.
Police reports are to be obtained in every case where a Police report was made.
Photographs are to be obtained in all premises liability claims and in property damage claims. Photographs on all bodily injury claims are requested to be taken of the claimant.
Diagrams should be used in complex cases only or upon request. Diagrams should be used only when photographs and narrative reports can not clearly convey the details of the claim. Use diagrams in conjunction with photographs (complex cases only).
Experts & Surveillance
Experts and surveillance should only be used with the approval of the claims manager and the insured/client.
Wage authorization should be requested in every case where lost wages are alleged.
Medical authorizations are to be requested on every bodily/personal injury case.
Reserves reflect our best estimate of the realistic exposure for indemnity and expense. As claim administrators we are responsible for the accurate and timely reserves which should be based on the most current information.
There is no single correct method of estimating loss reserves. We reserve based on the ultimate probable cost which consider circumstances as they exist to determine the amount that will eventually be expended at claim resolution. We acknowledge that this method may result in more frequent adjustments than other methods. However, we believe that it is to our clients benefit that there is an accurate picture of their exposure at any given time.
- be sufficient to meet all expected payments
- not be set solely based upon a formula
- be based upon documentation rather than gut feelings or unfounded expectations
- be explainable
- be regularly reviewed, but not necessarily revised
- Initial Reserves must be posted when entering a claim into our claim system.
Reserve Changes should be made whenever a development occurs that affects the exposure on the file. Stair-step reserving is unacceptable.
Expense Reserves should be set to cover expenses through the conclusion of the claim.
Reserves should be reviewed for accuracy at each diary date. All reserve changes should be documented and explained in both our report to the client as well as the adjuster activity log.
GOAL® (on complex matters in suit) The 1-year anniversary date from receipt of a claim, the case should be reserved for its conclusion. There should not be more that a 20% (+/-) variance from the anniversary reserves and the claims final paid amounts.
Documentation & Reports
Each file speaks for itself. If it is not documented in the adjuster activity log it didn't happen.
30 Day Report
A30-day report will be due on each file, unless circumstances preclude this time frame.
There will be an anniversary report due on the 1-year anniversary from the receipt of the loss. The anniversary report is a Full Formal narrative report.
Any other status reports will be in the Full Formal report format.
Coverage must be evaluated upon the receipt of all claims. In the event there is a question of coverage, the insurer must be immediately advised in writing.
As claim administrators we do not deny or disclaim coverage (unless instructed in writing by the client) or issue reservation of rights letters (unless instructed in writing by the client) .It is our responsibility to determine which policies or contracts apply to each claim and to recognize potential coverage issues.
In the event the service of legal counsel is needed, assignment must be made within 48 hours from receipt of the summons. Transmittal must be done via fax and express mail. If it is necessary to get an extension of time to answer a summons, it is imperative to secure a stipulation from the plaintiff;s attorney.
Follow Sweet Claims Company standard litigation management procedures.
*Remember - the claims adjuster controls the claim. The lawyer, doctor, contractor, salvor, expert, etc. are resources used to effect the best result possible. Take ownership of your files. There is a differencebetween managing and monitoring a file. Never relinquish control of the file to a vender or resource.
It is the adjuster's responsibility to review the Special Account Claim Instructions for each client to ensure compliance.