Expert Commentary

The Claims Professional as Problem Solver

Let's face it: claims are problems, and problems must be resolved. It logically follows then that claim handlers are professional problem solvers. With that perspective in mind, it stands to reason that claims professionals must undertake to become the best problem solvers they can be.


Personal Lines Claims
November 2014

Here are six tips to help resolve claim situations in an efficient and economical manner.

1. Define the Problem

First, it is necessary to determine what went wrong, how it went wrong, and to what extent. This requires good investigation skills coupled with excellent analytical skills. Used together, these critical skills assist the claim professional in determining the cause of the accident or event and the identity of the responsible party. Obtaining statements from involved parties and witnesses, analyzing the type and extent of the damages, and reviewing official reports will inform the decision as to who is liable for the loss.

A decomposition of the claim issues allows the adjuster to break down the issues into smaller manageable parts—for instance, facilitating a determination as to whether claim issues are based on coverage gaps, questionable liability, or undocumented damages. Determination of these issues focuses the investigation on the important facts to be uncovered, saving time and effort.

2. Define the Desired Outcome

Careful consideration of the facts uncovered during the investigation will assist the claim professional in determining the desired outcome. Deciding the desired outcome will focus the defense of the case toward that end. Certain actions will be initiated to achieve the outcome. By answering questions such as "Is this a claim that should be honored and paid?" or "Should this claim be denied and defended?" will assist the claim handler in creating a theory of defense that is supported by the investigation.

3. Remain Objective

Emotions can run high among the people involved in adverse events. By remaining objective, the claim professional can keep all of the stakeholders focused on the important issues without resorting to emotional outbursts. Emotions can also lead to poor decision-making on the part of the claims handler, thus hindering attempts to reach the desired outcome. Emotional maturity is a learned skill that can be relied upon to increase the confidence of the claim professional in believing that a resolution is attainable no matter how contentious the parties may be.

4. Know the Options

Once the claim issues have been determined and a theory of defense articulated, the claim professional must weigh the best course of action for reaching the desired outcome. This is the point at which knowledge of experts and vendors is very important. Use of claim mitigation vendors can assist in managing the scope of the damage; legal experts can assist with policy and coverage review; qualified physicians or independent medical exam experts can define injuries; and appraisers can itemize damages. Knowing when and how to use vendors is only part of the equation; knowing which ones will actually deliver is the second half. The efficient claim professional will know who can be relied on to deliver the service needed.

5. Develop the Expertise Necessary

Claim handlers fail because they do not have the expertise to perform the work that is required of them. They can't make a good decision about what to do if they don't know what needs to be done. Designation courses such as the Associate in Claims and the Senior Claim Law Associate programs provide excellent education on claims handling and offer bona fide credentials that a certain level of knowledge has been attained. In our ever-changing legal environment, knowledge is power, and excellent adjusters strive to have as much knowledge as possible.

There is no one single bit of knowledge that will ensure success. Broad knowledge about a variety of subjects will serve to assist the claim professional in resolving the claim issues that are presented. For instance, knowledge of the legal system, of repair techniques, of surgical interventions, and of fraud indicators are all tools that will prepare the adjuster to face a myriad of issues.

6. Maintain an Open Mind

It is difficult for the claim handler to solve a problem when there is only one foreseeable way to do so. Claims professionals require creativity to discover alternative solutions that will lead to claim resolution. Just because something worked in the past doesn't mean it will work now or ever again. Being open to new approaches and new ideas will keep the claim professional flexible in approaching claim issues.

Conclusion

Remember, claims are dynamic, occurring in an ever-changing environment. Solving the complex problems that arise from accidental or catastrophic events requires that the claim professional be well prepared in a number of important areas. No claim professional wants to be seen as the cause of a modern version of Jarndyce v. Jarndyce, making problem solving and claim resolution a keystone skill.


Opinions expressed in Expert Commentary articles are those of the author and are not necessarily held by the author's employer or IRMI. Expert Commentary articles and other IRMI Online content do not purport to provide legal, accounting, or other professional advice or opinion. If such advice is needed, consult with your attorney, accountant, or other qualified adviser.

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