In the firm where he is employed, a claims adjuster who was certified less than two years ago deals with claims files under $40,000. He is assigned to settle a claim resulting from an explosion in a commercial space. After investigation, damages are estimated at over $75,000.

According to the employer’s procedure, in cases such as this he must notify his supervisor who will team him up with an experienced claims adjuster to assist with the file. The adjuster neglects to do so and takes care of the claim himself.

The adjuster should not have disregarded this measure, which the insurer instituted to protect the public by ensuring that an experienced adjuster would be there to provide support on certain files.

An insured feels that the work of the claims adjuster assigned to her file caused her harm. She considers filing a complaint against him. The insured knows very little about damage insurance and is not particularly web savvy. She does not know who to turn to for help.

She asks the claims adjuster some general questions about finding resources that explain how damage insurance is regulated. The claims adjuster responds that he has too many files to manage, and it is not his responsibility to give her this type of information.

The claims adjuster’s response did nothing to promote measures that educate and inform. He should have directed the insured to resources that could help with her concerns such as the firm’s or the insurer’s complaints department, the ChAD or the Autorité des marchés financiers, or provide her with helpful information found in documents such as the Claimant’s Handbook or the checklist of organizations in the damage insurance ecosystem.

An insured’s garage is damaged by fire. The claims adjuster employed by the insurer sends him an estimate of $10,000 for the repairs. The insured informs the claims adjuster that he intends to get a second estimate from the contractor who built the garage, since he doubts that this amount is sufficient to repair the damages.

The adjuster tells the insured that he must agree to the insurer’s supplier if he wants speedy payment and a guarantee on the work.

The adjuster has misled the insured with this false representation. The claims adjuster should have advised him of his right to obtain estimates from suppliers of his choice so that he could make an informed decision regarding his claim.

An insured is preparing to go camping with his new fifth-wheel trailer. The day before he leaves, the trailer and all its contents are stolen. He declares the theft to his insurer.

The claims adjuster assigned to the file learns that the insured had not used the special lock required by the insurer to secure the trailer. Furthermore, he notes a number of inconsistencies in the information the insured provided. He therefore decides to transfer the file to the insurer’s special investigations unit, since the insured’s claim may not be allowable. However, the claims adjuster does not immediately notify the insured, nor does he give him a reservation of rights letter explaining the situation. The insured only learns of this a few days later when he receives a call from the investigator the insurer mandated to take his detailed statement of events.

The claims adjuster should have notified the insured of the steps the insurer intended to take with his file, in other words, that it would be investigating further to determine the admissibility of his claim.

An insured notices that the door of his vehicle has been smashed in and that items in the car were stolen, including hockey equipment, a golf bag and designer sunglasses.

The insured declares the theft to his insurer. The claims adjuster assigned to the file informs the insured that he must send him receipts for the stolen goods in order to receive compensation. The insured no longer has any proofs of purchase, but he has pictures proving that these items exist. The adjuster refuses to submit this evidence to the insurer.

The claims adjuster misled the insured by leading him to believe these receipts were mandatory. When a theft claim is made, insurers can agree to compensate the insured on the basis of other types of proof such as pictures. The adjuster should have submitted the pictures and let the insurer decide whether or not to compensate the insured.

The basement of an insured’s home suffers major water damage. She calls her insurer immediately. The floor and certain items are damaged. A claims adjuster collects the necessary information and takes the insured’s statement to put in the client-file.

Without explaining to the insured what will happen next, the adjuster mandates a disaster cleanup team and an estimator to assess the damages. The service providers arrive at her home although she has no idea what role they play in the claim settlement; they leave with certain items to clean. She also does not know what she should do or what to expect next in the claim settlement process.

The claims adjuster should have given the insured the explanations she needed to understand the services the various suppliers would provide. He should have also explained what the insured would have to do to try and save her belongings and the basic emergency measures needed to avoid aggravating the damage.

Water damage in a condominium building causes considerable damage to one unit as well as to the building itself. The two insurers involved—that of the co-owner of the damaged unit, and that of the syndicate of co-ownership—mandate the same claims adjustment firm.

The firm’s director assigns one adjuster to the co-owner’s file and another one to the syndicate’s file. He asks them to co-operate with each other and share information in order to ensure that the claim is settled smoothly.

The two adjusters cannot accept this mandate as presented by their director since it involves disclosing confidential information and documents to another claimant. That said, they can accept the mandate if the claimants and the parties involved consent to the two adjusters sharing information.

A fire damages a seniors residence. The claims adjuster mandated by the insurer visits the site and meets with the owner, who asks him if he is familiar with building standards and understands the unique features of seniors residences.

The adjuster responds that he has frequently worked on mandates involving this type of building and he is sure that the claim will be settled in less than a month. However, even though the adjuster has experience with residential claims, this is his first file involving a seniors residence.

The adjuster has misrepresented his level of competence and the effectiveness of his services. He should have admitted that this was his first seniors residence file, that there might be some delays in processing the file and that restoring the building might take longer than it would for other types of commercial properties.

A claims adjuster receives a mandate from the owner of an apartment building that suffered serious fire damage. The adjuster devotes significant time and energy to the file and succeeds in obtaining an excellent settlement for his client, the insured. The insurer sends the compensation cheque directly to the claims adjuster’s firm for it to then remit the money to the building owner. 

Before remitting the cheque to the insured, the adjuster asks the insured to immediately pay him his fees, although they had no prior agreement to this effect. The insured refuses, creating friction between the two parties. The claims adjuster therefore holds back the cheque, preventing the owner from paying for major work that needs to be done on her building.

The claims adjuster should not have held back money that was intended for the insured, even though the insured had not yet paid him his fees. He should have sent her the money as soon as possible.

An insured suffers major water damage to his home. The claims adjuster visits the home to estimate the damages. Given the extent of the damages—and with the homeowner’s consent—she mandates a team to collect the wet clothing and a mover to take out the damaged furniture and send it to a cabinetmaker for evaluation.    

However, she neglects to ensure that a detailed list of the clothing and furniture is drawn up and fails to instruct the transport company and the cabinetmaker to ensure the items are dried as soon as possible to avoid mould developing.

After three weeks of inaction, the clothing and furniture have continued to deteriorate and must now be declared a total loss. 

The claims adjuster should have been more careful with the property she was responsible for when carrying out her mandate. She should have continuously monitored how the claim was progressing and better managed both the emergency and the restoration work.

A claims adjuster is mandated by the owner of a restaurant to settle a claim for fire damage. After completing his mandate, the insurer sends him a compensation cheque made out to both the adjuster and insured.

Since he is having some financial difficulties, the adjuster asks the client to loan him the money until the repairs begin. The insured trusts him and agrees to the request. The adjuster then deposits the cheque in his personal account, intending to reimburse the insured by the agreed upon date once he has put his finances in order.

The claims adjuster should not have borrowed money intended for an insured who is his mandatory. He should have deposited the cheque in a separate account.

A fire damages an apartment building as well as the contents of one apartment. The tenant’s claims adjuster mandates a specialist to determine the cause of the fire. The report concludes that the fire was caused by the tenant’s negligence while he was doing unauthorized renovations.

The landlord’s claims adjuster hears about the specialist’s visit and asks the tenant’s claims adjuster for a copy of the report to find out the cause of the fire. Given the conclusions of this report, the tenant’s insurer forbids the adjuster from sharing the document. The adjuster therefore drags his feet about calling back the landlord’s adjuster and then lies, saying the report was inconclusive and that he will not provide it. In the meantime, physical evidence on the potential cause of the fire disappears.

The tenant’s claims adjuster should not have lied and misled the landlord’s adjuster. As soon as he received instructions from the insurer, he should have notified the other claims adjuster that he could not provide him with the requested document since his mandatory forbade him from doing so. This answer would have allowed the landlord’s adjuster to mandate his own specialist to determine the cause of the fire.

A truck carrying hazardous materials is involved in a pile-up on a provincial road and spills its cargo. The case involves a number of claims adjusters representing various parties including the company that owns the truck, the driver, the municipality, and the Ministry of Transport and the Environment.

One of the adjusters refuses to coordinate his investigation and the site cleanup with the others. In addition, he does not share any of the non-confidential information that the other adjusters have requested.

The claims adjuster has been uncooperative with the other adjusters involved in the file. Even though his first duty is to his mandatory, to whom he must not cause any harm, he should have cooperated with the other claims adjusters involved in the claim in order to ensure they were apprised of the facts and avoid causing them any harm.

A claims adjuster employed by an insurer is at loggerheads with the claims adjuster mandated by the insured—an adjuster who regularly works on extremely complex claims files. The insurer’s adjuster feels the insured’s adjuster has gone overboard with his requests for information and the settlement proposals he makes; all this eats into his time and slows down his work, even though the requests turn out to be well-founded.

In retaliation, he files a complaint with the Syndic’s Office of the ChAD.

The claims adjuster employed by the insurer should not have filed an unfounded, malicious complaint. Furthermore, if the Syndic’s Office determines that the complaint is malicious, it may investigate the claims adjuster who made the complaint in order to verify whether he violated this section of the Code.

This section refers to the claims adjuster’s obligation to protect, through his good conduct, the image of the profession and the public’s opinion of this image. It lists a number of situations where the claims adjuster is considered to have acted contrary to the honour and dignity of the profession. The honour and dignity of the profession may be defined as its respectability.

The word “including” means that the list of breaches is not exhaustive. A complaint concerning acts that are contrary to the honour and dignity of the profession can be lodged against a claims adjuster even if such acts are not listed in this section.

A claims adjuster enjoys using cannabis on weekends now that this substance is legally available.

During a particularly stressful period, he uses it much more frequently and this additional use affects his mental acuity while working on claims files.

Claims adjusters must always be in full possession of their mental faculties when at work. Any situation likely to negatively affect one’s ability to properly provide professional services must be avoided. Although cannabis is now sold legally, its use may affect an individual’s mental state and have a negative impact on their mental faculties. It should not be used within a professional context.

A young tenant suffers a loss. After investigating, the claims adjuster sends her a $5,000 offer of compensation to replace her damaged belongings and furniture. The insured discusses the offer with her father, a retired claims adjuster.

The father is unhappy with this offer; he believes that the items to be replaced are worth considerably more. He calls the claims adjuster and negotiates better compensation. The adjuster notes the father’s arguments and sends a request for review to the insurer.

A claims adjuster cannot allow his actions to be dictated by a third party—in this case, the father—who has become involved in settling an insured’s (the tenant’s) claim. The adjuster should have explained to the father that he had to settle the claim directly with the daughter since she was the named insured on the home insurance contract.

A claims adjuster is working on a file involving a burglary at an insured’s home. The list of stolen items includes three laptops. The adjuster doubts that the insured actually owned these devices and decides to ask him some questions. The insured admits that he added these items to help his children with their homework.

The adjuster offers the insured a deal: she will turn a blind eye to the falsely declared items if he gives her one of the three computers.

The adjuster should neither have encouraged insurance fraud nor benefitted from false evidence.

A claims adjuster is dealing with a claim stemming from an apartment building fire. Due to the loss, the tenants have been temporarily relocated and the building owner stands to lose significant rental income during rebuilding. Fortunately, his contract includes coverage for this situation, and he has a right to receive $10,000 in compensation.

The insured waits for his cheque for several weeks. When he asks the claims adjuster about it, she falsely tells him that she is waiting for the cheque from the accounting department; in fact, she actually completely forgot to enter an order to issue the cheque into the insurer’s system.

The claims adjuster should not have made a false statement to the insured to cover up her mistake. She should have been honest with the insured and admitted that she had forgotten to order that the cheque be issued.

An insured suffers water damage to his garage, which houses a huge freezer. The insured sends the claims adjuster the list of damaged items, including the freezer. The insured estimates that he lost $3,000 worth of frozen food.

Given the size of the freezer, the price of the food, and the number of people living in the home, the adjuster concludes that it is highly unlikely that the freezer contained $3,000 worth of food and says so to the insured.

The insured comes back with bills to prove the $3,000 loss. The adjuster immediately sees that these bills are bogus but decides not to challenge the insured and includes them in the claim file.

The claims adjuster should not have been party to using evidence he knew to be false. If the adjuster concludes beyond a reasonable doubt that the bills are false, he cannot include them in the claim file.

The luxury residence of a well-known businessman is engulfed in flames. A few weeks before the fire, the entertainment mogul had been accused of sexual assault on social media in the wake of the #metoo movement. The claims adjuster assigned to the claim thinks the man’s behaviour is disgusting.

Even though the insured tells the adjuster that the fire may have been started by the work being done on the house, the adjuster leans towards arson, aided and abetted by the insured himself. A neighbour tells her that he saw a suspicious person talking with the insured a week before the fire and saw this person again a few hours before the fire began. The adjuster tells the neighbour that he could be paid if he testifies that he saw this person set fire to the home. In so doing, she believes that the insurer will refuse to compensate the businessman.

The adjuster should not have offered financial compensation to sway his testimony to fit her hypothesis. She should have shown professionalism and obtained reports on the probable cause of the fire before coming to the conclusion that the insured was party to arson.

A fire destroys a house. The claims adjuster mandated by the insured visits the site to review the damages and meet with a restoration specialist. The claims adjuster is convinced the fire was caused by the insured’s faulty BBQ. The restoration specialist, however, believes that smoking was the cause.

The adjuster does not listen to the specialist and continues analyzing the site. He finds a smouldering cigarette butt. He destroys the butt before anyone else sees it to avoid any doubts regarding the insured’s liability for the fire.

The adjuster should not have destroyed a piece of evidence that was useful in settling the claim. He should have informed the insurer that he had discovered a cigarette butt so that the insurer could conduct its own investigation in full knowledge of the facts.

An insured is sued for civil liability for injuries suffered by a neighbour who had dropped by to visit. The insured had not cleared the ice off his driveway properly, and the neighbour fell and fractured his right leg. The claims adjuster takes note of the insured’s and the injured neighbour’s version of events.

The insured tells him that he has a security camera monitoring the driveway. The adjuster decides not to use this evidence in his file since it incriminates the insured and might complicate his work.

The adjuster should not have ignored evidence such as the security camera footage, which was discovered during his investigation. He should have kept this evidence and used it when processing the claim.

An insured’s oil tank spills accidentally on his property.

The claims adjuster assigned to the claim file recommends to the insured that he not notify the Ministry of the Environment in order to avoid complicating the file.

The adjuster failed to act with professionalism. She should not have suggested to the insured that he refrain from notifying the Ministry: this obligation is enshrined in the Environment Quality Act. On the contrary, she should have made sure that the insured did indeed contact the appropriate authorities.

An insured is a victim of burglary. The thief stole a television and some computer equipment. The insured declares the theft to his insurer and gives his version of events to the claims adjuster.

The adjuster verifies the insurance contract and mentions to the insured that since his deductible is high, he should use this opportunity to declare other items stolen, such as cash and small kitchen appliances. The insured takes the adjuster’s advice to heart and lengthens his list of stolen items.

The claims adjuster should not have encouraged the insured to commit fraud by lying about the stolen goods. This is completely contrary to the honour and dignity of his profession.

While settling a claim for water damage in a duplex, a claims adjuster neglects to properly follow up with the suppliers; as a result, the repairs do not proceed as planned, costs rise and there are scheduling delays. The insurer relieves him of his mandate and sends the case to the litigation department.

The adjuster believes he is no longer responsible for the claim and withdraws completely from the file without notifying the insured or any of the other parties.

The adjuster should have informed the duplex owner as well as the tenants that his mandate was terminated and that the file had been transferred to the insurer’s litigation department.

An insured suffers a serious fire in her home. Completely overwhelmed by the claims process, she considers the possibility of mandating a claims adjuster to represent her in her dealings with the insurer.

She meets a public claims adjuster the day after the loss. The adjuster insists that she immediately sign a contract mandating him to represent her in her claim. He contends that she must act quickly with the insurer—otherwise, the loss cleanup will not be done properly, and she will have trouble obtaining enough compensation to have the repairs done.

The claims adjuster should not have pushed the insured to use his professional services. He should have taken the time to explain his services to the insured so that she could give him truly informed consent. Although he has a right to build his client-base, prospecting must be conducted in a moderate and dignified manner, and without undue pressure.

An independent claims adjuster is mandated by an insurer to settle a claim of water damage to a commercial building.

The file requires 30 hours of work, but she decides to bill for 40 hours to top up her income. She lies about the tasks she performed to justify the 10 hours she overbilled.

The claims adjuster acted contrary to the honour and dignity of the profession; she should not have illegally padded her invoice. She should have billed accurate fees for the tasks she actually performed and explained the statement of compensation to her mandatory.

A claims adjuster is working on a home insurance claim. During the repairs, the house is uninhabitable, and the insureds must be temporarily relocated.

The insurer issues a first cheque to reimburse them for living expenses. The claims adjuster is short of money and decides to misappropriate this money, convincing himself that he will be able to reimburse the insureds within a few days.

The claims adjuster should not have acted contrary to the honour and dignity of the profession: under no circumstances may he use or appropriate, for personal purposes, money entrusted to him in the performance of his mandate. He should have remitted the insurer’s reimbursement to the insureds.