C111 Chapter 2 Advanced Loss Adjusting



  1. 3 aspects of a claim settlement the adjuster could explain to a claimant in order to manage expectations. – 1) Explain any obligations to the insured. 2) Explain the legal process, possible outcomes and timing. 3) Explain their right to retain a lawyer. Pg. 03
  2. List the steps to follow in reading a liability policy in light of a claim made against the policy.
    • Review the declarations-who is an insured.
    • Review that part that defines who qualifies as an insured in addition to the named insured.
      • Explore the history of the company.
    • Review the insuring agreement.
      • Has there been an occurrence?
    • Do any exclusions apply?
    • Do any exceptions to exclusion apply?
    • How do policy definitions for special terms modify the coverage?
    • How are limits of insurance to apply?
    • What endorsements if any will affect coverage?
    • Deductibles ?
    • Which of the policy conditions are of issue to the claim under review?
      • Insured must prove that the loss or claim is within the scope.
      • Potential size of the claim or severity of the injury. Pg. 04-05
  3. What information should the adjuster gather at first contact with insured? – How the insured was put on notice of the claim and about the scene of the accident (details...i.e. condition, when, has anyone investigated, etc.). Pg. 06
  4. Duty of care: Legal duty owed to a claimant that they adhere to a standard of care. Standard of care: is the degree of prudence and caution required of an individual who is under a duty of care. Pg. 06
  5. What duty of care does an employer owe its employees – a general duty of care to provide a safe workplace and proper tools. Pg. 07
  6. Vicarious Liability - responsibility of the superior for the acts of their subordinate. The liability is strict in that it does not matter whether the superior was negligent or not. Pg.08
  7. Defences to a Liability Claim
    • Elements of an actionable tort were met.
    • Damages were too remote from the breach.
    • Denial of damages or wrongful act.
    • An emergency excuses the wrongful act.
    • An act of god caused the damage.
    • Statutory defence to the claim.
    • Contributory negligence
    • Volenti non injuria ("to a willing person, injury is not done"). Pg. 09-10


  1. Why is reliable evidence crucial to any case?- Courts apply strict standards to evidence and it must stand up to challenge. Pg. 11
  2. How does the law deal with previously existing conditions aggravated by a new accident? – If there were no recognizable symptoms of previous condition, the law would qualify the accident as the cause of the new injury, the claimant could collect in full. Pg.12
  3. What is a “Material contribution”? - Courts have used the term "materially contributed" to establish negligence on the part of the wrongdoer when there are multiple causes for an injury. Insured would be liable though his or her act alone was not enough to cause the injury as long as they contributed to the injury. Pg. 11
  4. Thin skull theory - Thin skull theory provides the defendant must take the victim as he or she is and will not be measured against the “average” person. Pg. 11
  5. What is the standard of proof required to establish causation in civil law? – The level of proof in evidence must only satisfy a balance of probabilities to prove a fact (51%). Pg. 13
  6. Under what circumstances parents could be held liable for their children’s acts? – If the child is acting on the parents express instructions, the child is employed by the parents or, the parents allow a child to control a dangerous thing. Pg. 14
  7. How can a 3rd party claimant’s lawyer slow an investigation? How can an adjuster accelerate the process? A lawyer can restrict access to the claimant but an adjuster may send status letters directly to the claimant to accelerate the process.
  8. What factors could affect the value of a 3rd party claimant’s injuries? - This could be affected by age, culture, employability and lifestyle. Pg. 20
  9. Explain why compensation awards may differ between two claimants with the same injury. -  Compensation will vary according to how the injury has affected the lifestyle of the claimant.  Pg.20
  10. What kinds of claims and activities have been linked to possible fraudulent behaviour on the part of the claimant? – Subjective complaints (that cannot be verified) and excessive quasi-medical treatments are signs of a “planned” injury. Pg. 21
  11. How can claimant’s activities be documented to show inconsistencies with claimed injury? – Video surveillance is best. Pg. 21
  12. What questions can the claimant’s employer answer to help determine the value of a claim? –
    • What are the physical aspects of the job?
    • How will the injury affect the claimant’s ability to do the job?
    • Will the employer retrain or help during rehabilitation?
    • What is the claimants present and expected wages/income? Pg. 22
  13. What does the discount rate address? – The investment interest rate is often higher than the inflation rate, which leads to an overall reduction in the damages. Pg. 23
  14. What factors will affect the discount rate? – The discount rate considers how inflation affects a persons earnings. This will be affected by the claimant’s age, experience and education; job or position; the economy and inflation. Pg. 24
  15. When is a settlement grossed up? – In order to compensate for the decrease in award as a result of taxes applied. Pg. 24


  1. Describe some of the types of losses to be paid in the following catagories:
    • Special Damages

      • Must be specially pleaded and proven.
      • Represent actual expenses resulting from the injury from the date of injury to the date of the trial.
      • Loss of working capacity refers to incurred loss of earnings.
      • Cost of care includes out-of-pocket expenses for health-related issues.
      • Claims for damage to property at the time of the accident.

    • Future Loss of Working Capacity  
      • Refers to less tangible losses that are anticipated to happen as a result of this injury.
    • Future Cost of Care
      • Includes expenditures yet to materialize for medical and hospitalization expenses for changes in a post-accident living environment.
    • Capital Expenses
      • Refer to one-time expenses such as the purchase of a wheelchair or the reconstruction of a home.
    • Ongoing Expenses
      • Refer to services on a regular basis: if lump sum negotiated generally a claim will be presented for a grossed up sum when taxation is expected to cut into the damage award.
    • Non-Pecuniary Losses
      • Damages that cannot be calculated with any precision mathematically.
      • Adjuster can expect to find demands for pain and suffering, loss of amenities, loss of expectation of life, and aggravated damages.
      • Pain and suffering includes distress caused the physical injuries.
      • Loss of amenities concerns the physical and emotional consequences of the accident sustained by the claimant.
      • Loss of expectation of life compensates claimant for anticipated shortened life span.
      • Aggravated damages are typically awarded in cases of intentional wrongdoing by the defendant.
      • Care, guidance, and companionship arises from dependants according to enabling provincial legislation, which permits relations to sue for the loss of care, guidance, and companionship .
      • Relational harm claims from other affected parties with a special relationship.
      • Allowable damages include actual expenses reasonably incurred for the benefit of the person injured or killed.
      • Any claim made will be limited by the injured party's contributory negligence. Pg 24-25


  1. How are claims for relational harm enabled in common law? – arises from dependants with special relationship. Usually includes spouses, children, grandchildren, parents grandparents, brothers and sisters. Pg. 26
  2. Civil Code of Quebec? – Article 1457 places no restrictions on who can sue for injuries caused by a wrongful act. Pg. 26
  3. What must be demonstrated in order for a claim to be accepted? – A recognizable injury and a causal link between the injury and fault. Pg. 26
  4. What are the benefits of a lump sum payment for the claimant? And insurer? The claimant can make further investment. The insurer benefits by the fact that the case is closed and no further amounts or management is involved. Pg. 28
  5. What are the components of a structured settlement? How are structured settlements often funded? – A financial package designed to meet specific future payment requirements. This includes an initial lump sum to pay for medical expenses, lost wages, special equipment, lawyers fees and other incurred expenses to date. These settlements are often funded by setting up a trust or buying an annuity. Pg. 27
  6. Why is it unwise to admit liability when a decision is made to pay a claim? – This gives the insurer more flexibility at a later date to argue that the claim was not the result of the insured’s negligence should it ever go to court. Pg. 28
  7. Under what circumstances can a release be overturned? – If the settlement was grossly unrealistic or the claimant did not have opportunity to consult with council. Pg. 29
  8. What processes are different when closing a claim with a minor? – Settlements require approval by a public trustee or a judge. If the injury is minor then the parents or guardian can settle.
  9. Under what circumstances would an adjuster be concerned with apportioning defence costs? – When the some of the issues of the claim are not recoverable under the insurance policy.