C111 Advanced Loss Adjusting : C111 Chapter 4 Advanced Loss Adjusting

Who mandates automobile insurance policy wording? – Provincial law. Pg. 03

Why are accident benefits referred to as no fault? – They are payable to policy holders regardless of who is at fault. Pg. 03

What medical knowledge should an adjuster have in order to assess automobile injury claims? – Understand associated medical terminology, optimum course of treatment, limitations injuries could impose, length of time injury could affect individual. Pg. 04

How are injuries Compensated? Who sells & Administers Auto? What does basic coverage include? What rights does the injured party have?

AB Under liability section of policy Private Insurers Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits Right to sue for pain and suffering and economic loss in excess of no-fault benefits

BC Under liability section of policy Government. Private insurers compete for optional coverage Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits Right to sue for pain and suffering and economic loss in excess of no-fault benefits

Man ? Government. Private insurers compete for optional coverage Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits NO right to sue for pain and suffering or economic loss

Newf Under liability section of policy Private Insurers Optional first party Medical payments, Rehab costs, Funeral, disability and death benefits Right to sue for pain and suffering and economic loss in excess of no-fault benefits if optional insurance

NB Under liability section of policy Private Insurers Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits Right to sue for pain and suffering (with cap) and economic loss in excess of no-fault benefits

NWT Under liability section of policy Private Insurers Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits Right to sue for pain and suffering and economic loss in excess of no-fault benefits

NS Under liability section of policy Private Insurers Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits Right to sue for pain and suffering and economic loss in excess of no-fault benefits

Ont Against one’s own insurer Private Insurers Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits Only Catastrophic injuries can sue for pain and suffering.

PEI Under liability section of policy Private Insurers Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits Right to sue for pain and suffering and economic loss in excess of no-fault benefits

QC No fault basis under schedule of benefits. Government. May purchase QEF 34 accident benefit endorsement from private insurer Outlined in Schedule May sue for damages if outside of Quebec

Sask Under liability section of policy Government. Private insurers compete for optional coverage Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits Right to sue for pain and suffering and economic loss in excess of no-fault benefits (if at fault driver is convicted of crime)

Yuk Under liability section of policy Private Insurers Mandatory Medical payments, Rehab costs (modest limits), Funeral, disability and death benefits Right to sue for pain and suffering and economic loss in excess of no-fault benefits

Define Commuted value – The amount that it would take today to pay off an accrued benefit that is due in the future. Pg. 07

When automobile accident occurs out of province, what arrangements must the adjuster determine? – Any Reciprocal arrangements for claim settlement. Pg. 10

Why must adjuster meet with injured party as soon as possible? – To get details of accident, injury, and claimants activities and employment history – Injured may lawyer up.

What expenses will the insurance adjuster have to review for rehabilitation? What are the steps in the rehabilitation process? – Original invoices for physiotherapy, medical aids, prosthetic devices, prescription drugs, chiropractic expenses and dental treatments should be reviewed. The rehab process may involve assessment, goal setting, planning, training, placement and follow-up. Pg. 11

What expenses will need to be reviewed for wage loss? – Employment history, Salary/wage and benefits details. Pg. 12

What are the general criteria for collecting for wage loss? What details are important and what are the rights of the insurer? – The claimant must be unable to perform the usual duties of his occupation...eventually it will be tested that he is unable to perform any occupation. Documentation from family doctor is required and the insurer may seek independent medical opinion and even employ a private investigator. Pg. 12-13

How is the death benefit calculated? What documentation/proof is required? – Death benifits are calculated based on the status of the insured in the household. Death certificate and proof that the death was a result of the injuries. Proof of relation may also be required (i.e. marriage certificate). Pg. 13

How are damage amounts calculated? – The total of:

Out of pocket expenses

Temporary total and partial disability (wage loss)

Permanent disability (wage loss and loss of use)

Pain and suffering. Pg. 16-17

Define insurance fraud and how governments discourage it. - Knowingly make false or misleading statements or representations (including documents) to an insurer or wilfully fail to inform an insurer of a material change. Heavy fines and jail time are possible outcomes of Insurance fraud. Pg.17

When are outside experts brought in to determine cause and fault? – The greater the value of a claim, the greater the justification for hiring an appropriate expert. Pg.18

What information is included in a loss report? –

name and address of the insured;

driver's license;

policy number;

date, time, and place of the accident;

brief description of the accident;

damage sustained by insured;

identification of the third party;

names of witnesses, if any;

names of all parties who sustained injuries; which vehicle were they traveling in, if any.

Pg.19

What type of benefits could be deducted from an automobile settlement in your province? – Collateral benefits (?). Pg. 20

What is the effect of signing a settlement release? – Gives up any rights to make any further claims for the injury, now or in the future. Pg. 21

What should the adjuster advise the claimant before signing the release? – To seek expert (legal) advise. Pg. 21

What is uninsured motorist coverage? – Allows for an insured’s own policy to provide compensation if an injury is caused by an uninsured or unidentified vehicle. Pg 21

What coverage does non-owned automobile policy provide? – It is an endorsement that covers an insured that drives a vehicle for business not owned by the insured. This covers an insured if the at fault vehicle is uninsured or underinsured, defence costs are also covered. Pg 22

	How are injuries Compensated?	Who sells & Administers Auto?	What does basic coverage include?	What rights does the injured party have?
AB	Under liability section of policy	Private Insurers	Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits	Right to sue for pain and suffering and economic loss in excess of no-fault benefits
BC	Under liability section of policy	Government. Private insurers compete for optional coverage	Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits	Right to sue for pain and suffering and economic loss in excess of no-fault benefits
Man	?	Government. Private insurers compete for optional coverage	Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits	NO right to sue for pain and suffering or economic loss
Newf	Under liability section of policy	Private Insurers	Optional first party Medical payments, Rehab costs, Funeral, disability and death benefits	Right to sue for pain and suffering and economic loss in excess of no-fault benefits if optional insurance
NB	Under liability section of policy	Private Insurers	Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits	Right to sue for pain and suffering (with cap) and economic loss in excess of no-fault benefits
NWT	Under liability section of policy	Private Insurers	Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits	Right to sue for pain and suffering and economic loss in excess of no-fault benefits
NS	Under liability section of policy	Private Insurers	Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits	Right to sue for pain and suffering and economic loss in excess of no-fault benefits
Ont	Against one’s own insurer	Private Insurers	Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits	Only Catastrophic injuries can sue for pain and suffering.
PEI	Under liability section of policy	Private Insurers	Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits	Right to sue for pain and suffering and economic loss in excess of no-fault benefits
QC	No fault basis under schedule of benefits.	Government. May purchase QEF 34 accident benefit endorsement from private insurer	Outlined in Schedule	May sue for damages if outside of Quebec
Sask	Under liability section of policy	Government. Private insurers compete for optional coverage	Mandatory Medical payments, Rehab costs, Funeral, disability and death benefits	Right to sue for pain and suffering and economic loss in excess of no-fault benefits (if at fault driver is convicted of crime)
Yuk	Under liability section of policy	Private Insurers	Mandatory Medical payments, Rehab costs (modest limits), Funeral, disability and death benefits	Right to sue for pain and suffering and economic loss in excess of no-fault benefits