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Claims PowerPoint Presentation

Claims

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Claims

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  1. FNOL (First Notice of Loss) Coverage Auto lines 1st Party 3rd Party Insured car Insured driver Property lines On premises Contents Structure Off premises Casualty files 1st Party 3rd Party Damages Auto Casualty 1st Party 3rd Party Property Settlement Auto/Property Casualty 1st Party 3rd Party Claims

  2. Scenario 1 The insured is a part time college instructor at a small local community college. His 1992 Dodge Ram pickup has been up on blocks for 18 months while he makes repairs to the transmission. The truck has not run at all during that time, but the insured still carries comprehensive coverage on the vehicle. One day the vehicle catches fire and is totaled. The insured makes a claim for the total value of a 1992 Ram pickup. Due to the unusual nature of the fire, you hire an independent cause and origin investigator who finds positive evidence of accelerants in the seat area of the truck. Burn patterns show that is where the fire started and burned at the greatest temperature. The insured offers no explanation as to why there would be accelerants in the cab area of the truck. • Do you pay the claim? • If you do, do you pay the book value of a 1992 Dodge Ram pickup, or a greater or lesser amount?

  3. Scenario 2 A professional sports figure engages in what he believes to be a consensual physical relationship with a female admirer. Weeks after the encounter, the female charges the athlete with rape and files a claim for damages. The athlete turns over the civil lawsuit to you, the insurer. Your policy excludes coverage for intentional or criminal acts. • What issues affect your coverage decision? • What would you do?

  4. Scenario 3 A 4 year old child runs out from between two parked vehicles onto a busy suburban street just after dark during rush hour. He is hit by your insured who was traveling within the posted speed limit. There is no evidence of any impairment on the part of your driver. The family of the child makes a claim for his extremely serious injuries against your insured’s $20,000 liability policy. • What do you do? • Now assume the insured has a million dollar umbrella policy. Does this affect your decision? • Why or why not? • Change the age of the child to 10. Same decision?

  5. Scenario 4 Your insureds own a home with an in-ground swimming pool. The policy carries a $100,000 liability coverage in addition to the protection for the home itself. In early spring, before the pool has been cleaned for the season, the insured’s twenty five year old son has friends over in the backyard. Despite the posted “No Diving” sign painted on the concrete, one of the guests decides to dive into the murky water, hitting his head in the shallow end of the pool. The claimant’s injuries include permanent quadriplegia, which will involve long term continuing medical care. A policy limits demand is made against the carrier. • What do you do? • Assume the injured guest was intoxicated. Any difference in your decision? • Assume the injured guest was both intoxicated and under age. What now? • Assume the injury was a broken leg instead of quadriplegia. Any change in your opinion?

  6. Scenario 5 An insured hires a young female from a Central American country to perform household duties for his wife. The insured speaks no Spanish, the domestic employee speaks no English, but the insured wife speaks both languages fluently. The live in employee eventually claims she has been physically abused by the wife and makes a claim for damages against the homeowners policy. Evidence supports her claim. The husband claims that since he did not speak Spanish he had no way of knowing what was alleged by the girl, and was unaware of the abuse allegations. Your policy excludes coverage for intentional and criminal acts committed by an insured person. Is there coverage for this loss?

  7. Scenario 6 • You issued a standard homeowners policy to the insureds. They suffer a water loss involving an overflowing bathtub. Due to the apparent minor nature of the damage, the insureds repaint the ceiling and clean the area themselves. 18 months later, while the insureds are tryng to sell the house, a home inspector for the prospective buyers finds a serious mold problem in the ceiling and walls adjacent to the damaged area. The insureds make a claim against the homeowners policy for the mold remediation. Your policy covers only sudden and accidental losses. Your decision? •  What if mold was discovered, but there was no original water loss?

  8. Scenario 7 A teenager throws a party in his parents’ home while they are out of town. Some under-aged guests become intoxicated. On the way home one of these under aged guests is involved in a tragic accident, which kills someone in the other vehicle. The homeowners and the homeowners son are sued, along with the driver. The Homeowners policy contains the standard exclusion for losses that involve a motor vehicle accident. The Auto policy only grants coverage for listed vehicles, or non-listed vehicles driven by an insured person. • Where is the coverage for this loss on the behalf of the homeowners and their son? • Is there liability on the part of the insureds and their son for this loss? • Does it matter if the parents are home? Does it matter if the son charged a fee to get into the party? Why or why not?