When you have a claim against either your insurance company, or file a claim against another insurance company, you will deal with an “adjuster”. The first question that most people ask is what is an adjuster? This is typically an employee of the insurance company whose job it is to investigate all aspects of the claim and attempt to resolve the claim as quickly as possible. The State of California through the Department of Insurance has standards called Fair Claims Practices Acts which mandates that insurance carriers promptly investigate claims. 

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What the adjuster does is attempt to speak with all the parties involved in the incident (called a date of loss) by the insurance company. The adjuster will either obtain information from the parties involved either by telephone or in person. This information may take the form of a written statement, recorded statement and photographs if needed. Insurance carriers need their insureds to cooperate with them in the investigation of a claim. In order to ensure cooperation of their insureds, the insurance contract (the policy) typically contains a   “cooperation clause”.  If the insured fails to cooperate with the insurance carrier in their investigation, the insurance carrier may not provide coverage to their insured for the loss/incident. This is a situation that you (as an insured) do not want to get into.

The primary purpose that people purchase insurance (aside from it being mandated by the State ) is to have a vehicle to provide compensation to people that we may hurt or if you are a claimant who has been hurt or damaged by the negligence of an insured.  When a claim comes into an insurance carrier, the insurance carrier establishes “reserves”. What a reserve quantifies   is the company setting aside what the “value of the case is”   and ensuring that there are adequate funds to pay this matter.

Once this is done, the adjuster gets the claim. The adjuster then begins an investigation of the claim itself. He/she will speak to the insured or employee of the insured to ascertain their version of the claim. They will do the same for the other side(s) of the claim. In the case of an auto accident, once the claimant has finished treating, the adjuster will obtain all of the relevant medical bills and records and will review them. If there are any additional documents, (e.g. police report, loss of earnings documents, etc). the adjuster will take this into account as well. Once all of the documents have been obtained, the various insurance carriers have used different computer programs to assist them in arriving at a “settlement range” for the matter. The adjuster will then contact the claimant directly (if there is no attorney involved) or the attorney for the claimant to attempt to resolve the matter.

The items used by the adjuster (in the case of a car accident) will be what is the liability (fault) of their insured like? Is the liability completely adverse to their insured, or is there some basis to place liability elsewhere? How severe is the impact to the claimant? Lower property damage cases are commonly referred to as MIST (Minor Impact Soft Tissue Injury) cases.  While injury in these matters is not ruled out, it becomes more difficult for the claimant to convince the adjuster that injury occurred. This is why these types of cases are fought by the insurance carriers.

Medical records are of key importance in attempting to resolve a claim at the earliest stage. The reports must be clear and concise. They must outline the injuries and what was done for the claimant.  In addition, the carriers use the “Index System”. What this is system entails is many carriers submit claims information to a clearing house that provides identifying data for claimants to ensure that all claims submitted   by the claimant are accounted for. The odds of “slipping one past the carriers “  are not in the claimants favor. The claimant must be truthful in all aspects.

The insurance carriers are operating from a position of strength today. They know that if a claim goes into litigation that juries are not overly generous in most cases. They know that plaintiff attorneys must have “the goods” if they choose to take a case into litigation. Costs of litigation mount quickly and in order to justify these costs the claim must have value to justify these expenditures.

Despite all the rhetoric of the insurance industry (e.g. you are in good hands will Allstate, etc), remember, these companies are not looking out for the well- being of the claimant. They are looking out for the well-being of their insured and their shareholders. The carriers are not on your side. This is why the adjuster will always attempt to resolve claims for the least amount of money possible. It is wise to consult an attorney prior to giving up your rights by signing a release (your giving up your rights to pursue the carriers insured).