AIC 300: The Evolving Role of the Claims
Professional Questions with Correct Answers
Primary mission of the Claims Department
To conduct good-faith investigations and pay only legitimate, covered claims.
Staff claims representative
An insurer employee who handles claims for excl inside or does field work
Independent adjuster
An outside professional hired when staff is busy or specialized skills are needed or
specialized skills are needed
Third-party administrator (TPA)
An organization hired by self-insured businesses to handle claims and record-keeping.
Producer
Agents, brokers, or intermediaries who place insurance with insurers.
Public adjuster
A professional hired by the insured to protect their interests and negotiate settlements. The
insured, in turn, pays the public adjuster's fee, which is usually a percentage of the settlement.
used when neg are not to the insured's liking
Relationship: Claims and Underwriting
Claims ensures fair payment; Underwriters provide data on coverage circumstances.
Line underwriters
, Evaluate new submissions and perform renewal underwriting with producers/applicants.
Staff underwriters
Manage risk selection and coordinate product, pricing, and guideline decisions.
Denial message requirement
Good-faith handling requires explaining the rationale behind a negative decision.
Loss ratio
A formula comparing losses and LAE against collected premiums. high loss ratio bad =
methods to reduce expenses
Loss adjustment expense (LAE)
The cost incurred to investigate, defend, and settle insurance claims.
Claims audit
Evaluation of claim files to ensure compliance with best practices.
Quality measures in Claims
Best practices, claims audits, and customer satisfaction data.
Purpose of expert collaboration
To evaluate loss cause/value, investigate fraud, or provide legal advice.
Self-audit
A claims audit performed by the same staff who work on the files.
Marketing and Sales claims usage
Rely on thorough claims data to devise targeted-marketing strategies.
Professional Questions with Correct Answers
Primary mission of the Claims Department
To conduct good-faith investigations and pay only legitimate, covered claims.
Staff claims representative
An insurer employee who handles claims for excl inside or does field work
Independent adjuster
An outside professional hired when staff is busy or specialized skills are needed or
specialized skills are needed
Third-party administrator (TPA)
An organization hired by self-insured businesses to handle claims and record-keeping.
Producer
Agents, brokers, or intermediaries who place insurance with insurers.
Public adjuster
A professional hired by the insured to protect their interests and negotiate settlements. The
insured, in turn, pays the public adjuster's fee, which is usually a percentage of the settlement.
used when neg are not to the insured's liking
Relationship: Claims and Underwriting
Claims ensures fair payment; Underwriters provide data on coverage circumstances.
Line underwriters
, Evaluate new submissions and perform renewal underwriting with producers/applicants.
Staff underwriters
Manage risk selection and coordinate product, pricing, and guideline decisions.
Denial message requirement
Good-faith handling requires explaining the rationale behind a negative decision.
Loss ratio
A formula comparing losses and LAE against collected premiums. high loss ratio bad =
methods to reduce expenses
Loss adjustment expense (LAE)
The cost incurred to investigate, defend, and settle insurance claims.
Claims audit
Evaluation of claim files to ensure compliance with best practices.
Quality measures in Claims
Best practices, claims audits, and customer satisfaction data.
Purpose of expert collaboration
To evaluate loss cause/value, investigate fraud, or provide legal advice.
Self-audit
A claims audit performed by the same staff who work on the files.
Marketing and Sales claims usage
Rely on thorough claims data to devise targeted-marketing strategies.
