Claims adjustment: roles and responsibilitesClaims adjustment: roles and responsibiliteshttp://chad.ca/en/members/professional-practice/toolbox/claims-adjustment/472/claims-adjustment-roles-and-responsibilitesRèglement de sinistres : rôles et responsabilités

​​​​​“A claims adjuster is a natural person who, in the field of damage insurance, investigates insured losses, appraises damages and negotiates the settlement.” ». For claimants, the aduster is the driving force behind the claims processus: he answers their questions and provides them with the information they need to make informed decisions..

Adjusters are veritable orchestra conductors who oversee a process involving many different players. They must act professionally, fulfilling their responsibility to inform, explain and monitor. During the review of the Sharing of Roles and Responsibilities in Claims Adjustment tool, many of the observations received indicated the potential for confusion around the role and responsibilities of the claims adjuster. Let’s briefly review the facts.


Providing the Relevant Explanations

The claims adjuster must provide the insured with the information he needs to understand his file. The adjuster is responsible for explaining deductibles, exclusions, and the applicable insurance limits. Furthermore, the adjuster is the only person who can explain to the claimant the purpose and scope of the consent to collect information, which is required to conduct the investigation.

If the claims adjuster has been assigned after emergency remediation has begun, he must ask the claimant or the service provider to brief him as soon as possible in order to determine, amongst other things, whether the insurance limits will be reached or exceeded. The claims adjuster must assess the situation and explain it to the claimant, including whether the costs incurred will be reimbursed. If costs are not reimbursed, or if the claim is completely inadmissible, who will be responsible for payment?


Maintaining Control

The claims adjuster must maintain control over the claims process, which may involve numerous players, as well as ensure that he has a complete picture of the situation.

Claims adjusters are exclusively responsible for certain activities. From an ethical perspective, when an adjuster mandates a disaster recovery supplier or a specialist to carry out certain tasks related to these activities, the adjuster nevertheless remains responsible for the work. The claims adjuster must therefore carefully define the mandate he has given the suppliers and ensure that they carry it out correctly. For example, in order to assess the damages and establish the amount of compensation, a supplier may have to take measurements and pictures.

However, even if the claimants have mandated the supplier, the claims adjuster must maintain control over the claim, and supervise the supplier’s work in order to ensure that its scope and value correspond to the evaluation negotiated with the claimant.

Though it is essential for the claims adjuster to be present from the very beginning to ensure that the claims settlement process starts out on the right foot, certain issues may delay his arrival on the scene. For example, many insurers offer to open the claims file as soon as they receive the first call, in order to speed up client response times. However, to make sure that he is fully in control of the process, when the claims adjuster meets the claimant for the first time, he must immediately verify the accuracy of all the information received and add any missing information, if need be. Only then will he be able to properly start his investigation.


Exercising Professional Judgement

Controlling the claims process depends not only on the adjuster’s understanding of the file as a whole, but also on his being able to exercise his professional judgement.

Estimators or assessors may be called to the site of the loss, either due to the potential complexity of the evaluation, or to support the claims adjuster in his work. The adjuster must familiarize himself with their reports to verify the consistency of the information contained in the reports and properly understand the situation. He must also question the specialists and suppliers regarding their conclusions, for example to evaluate whether further study or adjustments are required. This is particularly important if the reports are contradictory or if the evaluations vary significantly.

Since it is his responsibility to rule on the cause of the loss and whether the claim is admissible, it is important that the claims adjuster render his decision completely independently after having closely examined all the information at his disposal. Many specialists or suppliers may work on the claim and make observations or draw conclusions on its probable causes; sometimes their reports may be contradictory. However, it is the claims adjuster’s responsibility to review the various specialists’ reports and then rule on the cause of the loss, in order to then determine whether the claim is admissible and the contract applies.

By guiding the claimants through every step of the claim, the claims adjuster helps to simplify and speed up the process. Indeed, in a recent study, almost three claimants out of four expressed how beneficial it was to have a claims adjuster by their side.3

3. Sondage Perception des Québécois à l’égard de l’industrie de l’assurance de dommages [Quebeckers’ Perception of the Damage Insurance Industry] survey conducted by Léger for the ChAD, January 2016.


The issue of emergency work

​​When losses occur during the evening or on the weekend, claimants’ calls may be forwarded to an emergency call centre. The employees of such call centres are not necessarily certified and may not even have any connection with the insurer.

​​They collect the information provided by the claimant, open a claim file and, in certain cases, mandate suppliers. For claimants, this process is far from transparent. The explanations they receive are insufficient or insufficiently clear, be it with respect to the process, the admissibility of their claim or, where applicable, who will be responsible for paying for emergency work.

​​Currently there are no uniform standards for emergency work. The evaluation of the scope and cost of work for the same claim may vary depending on the supplier. When the limits of insurance are low, as is the case for water damage, suppliers and insureds must be informed of this fact. Such information allows the insured to decide whether to authorize work or repairs and to understand the consequences, in particular regarding who will be responsible for paying for cost overruns.

​​Remember that it is essential for a claims adjuster to be there as soon as the claims process begins. A claims file should always be managed by a certified professional.

9/16/2016 7:08:52 PM