Episode #76 - Back to School with the Unfair Claims Practices Act

✏️ School’s back in session—and so is claims compliance. In this episode, Chantal and Heather Blevins break down the Unfair Claims Settlement Practices Act and what it really means for adjusters in today’s high-pressure environment. From documentation do’s and don’ts to why clear, proactive communication can keep you out of hot water, this conversation is all about building good faith habits.

🎧 Tune in to hear practical strategies for avoiding costly mistakes, improving policyholder interactions, and handling claims with litigation in mind. Whether you’re a seasoned adjuster or new to the field, this episode gives you the tools to pass the “good faith” test every time.

For more insights, you might consider a career in liability adjusting or if you're searching for reliable adjusting services, visit Auten Claims Management.

To explore more about Chantal Roberts and her contributions to the industry, visit CMR Consulting.

Promotions:

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Chapters

• 0:00 Introduction to Good Faith Claims Handling
• 10:52 Communication: The Adjuster's Essential Tool
• 27:09 Starting a Reasonable Investigation
• 33:55 Payment Obligations and Reservation of Rights
• 43:20 Estimate Accuracy and Line Item Pricing
• 55:20 Protecting Yourself from Bad Faith Claims

Transcript

Speaker 1: 0:00

I'm Bill Auten of Auten Claims Management.

Speaker 2: 0:02

I'm Chantel Roberts of CMR Consulting and welcome to the Art of Adjusting podcast.

Speaker 1: 0:07

Today we're going to talk about life as an insurance adjuster from the perspective of property, auto liability or workers' compensation adjusters. Our goal is to bring interesting topics in the world of claims adjusting to people who are working as an adjuster now and to people who are considering a career as a claims adjuster.

Speaker 2: 0:24

Hi, heather, you are new. Welcome to the Art of Adjusting podcast, which you've actually already been on. So hey, go check out that one which you know what. I didn't even look up to see which which episode number it was, but um, there you go. Uh, probably put it in the show notes or something.

Speaker 3: 0:47

Yeah, hi, we are Hi there and we're definitely, I understand, going to talk about something completely different than the last time that I was on the show.

Speaker 2: 0:56

Yes, yes, we are. So Bill is still on vacay no, not really on vacay, no, not really. He has had a blessing fall into his lap, which is a lot of work and everything. So he's getting everything set up and in the interim, I am filling the spots with some guest co-hosts and you are going to be our guest co-host for the next six episodes.

Speaker 1: 1:26

Woo.

Speaker 2: 1:27

Yay, yes, and so you know we are getting ready to go back to school. Uh, everybody, um, thank God I no longer have children, um, because I hate the little ankle biters to begin with. Uh, and yes, I realized that that's being recorded and it's going to be all over the air. Actually, my eldest stepson is a claims adjuster. Hi, mike, love you and yeah, so, anywho, but I know a lot of people are going having kids go back to school and I thought we could also go back to school as adjusters and talk about good faith claims handling, because I usually do this episode with Bill at the beginning of the year for New Year's resolution. But we did have the tree doctor, the tree guy, come in and check out that episode, because it's actually really, really interesting to learn about trees and when you cut them down and how to cut them down, and it's a whole thing that adjusters really need to know.

Speaker 3: 2:35

So we are going to talk about the unfair claims settlement practices Act, and so, hi, welcome to the podcast yeah, absolutely, um, the back to school theme is fantastic because obviously, um, right now where I'm at, there's two kids in the house that we're staying in and they have gotten back into their early morning routines and everything. And I just, I just know that I will defend you, chantelle, if there's like some headline out there that Chantel Roberts hates children.

Speaker 2: 3:10

Thank you, thank you. I appreciate that and that's what friends are for. That's what friends are for. You're obviously not listening or here to listen to me sing off key, but you mentioned a good point is that the kids are getting back into their routines, and I think that this is what our adjusters need to do as well, which is why this is so important to me to talk about it routinely on the podcast every single year.

Speaker 2: 3:38

Like I said, usually it's at the beginning of the year, and that is is the Unfair Claims Settlement Practices Act, and I understand because I have been an adjuster I have had 300 claims before, with the 15 phone calls in an hour, 30 emails and five minutes that you can't possibly live up to all of these rules, not to mention the key performance indicators that management is wanting you to do, and for whatever short-sighted reason well, I know what short-sighted reason it is whatever short-sighted reason well I know what short-sighted reason it is, but that's a whole nother podcast, as Sandy and I used to say, is that the upper management will not hire more adjusters, and that is what makes it so hard.

Speaker 2: 4:37

But that doesn't keep you from getting sued for bad faith, which is what I now see as an expert witness, and so, look, I am here to put myself out of business. Is is essentially what I'm here for. That is what I am here for and, um, I think you kind of would like that as well, not to put me out of business, necessarily, but you're in charge of, like, the institutes now, I think, and you're still with CPCU publications, aren't you?

Speaker 3: 5:13

Yeah, yeah, I'm still chairing the publications and then I'll be stepping on to the leadership council next year. So yeah, and you know the the reality is is like obviously we all understand today's world. There's so much heightened stress on the claims function because, I don't know, litigation is absolutely out of control. There's this trademark word called nuclear verdicts out there right now and every adjuster is underneath the pressure of control. There's this trademark word called nuclear verdicts out there right now and every adjuster is underneath the pressure of that in their job role.

Speaker 3: 5:51

And I remember in my days of adjusting that you know we had a model of claim handling and everything and the practices that had to be put into place and it was very much to help to defer or, you know, kind of kick away some of those things that can get adjusters in trouble when they're handling clean files.

Speaker 3: 6:14

Yes, and, and I think you have to constantly ground yourself back in that and and take a, you know take stock with every file that you look at Am I meeting the time requirements? Am I following the guidelines associated with how long I have to make a decision about this particular claim file? And I get like the stress and the pressure of that is super high today because of KPIs and, you know, feeling like there's not enough staff and there's this vacuum of experience that's going out of the industry as well, that knew all that stuff that everybody today coming in may not be fully aware of. So keeping adjusters abreast of those requirements on a regular basis I think has to be part and course to everything that you're doing in your day-to-day handling as claim handlers today, especially because of the heightened pressure of the litigation environment.

Speaker 2: 7:19

Yeah, so I mean, you mentioned one of these things that is so important is keeping everybody up to date, and that is one of the key things that the Unfair Claims Settlement Practices Act talks about. By the way, adjusters, when you're listening, agents, when you're listening if you want to know what the adjusters rules are, what their duties are, you can Google Unfair Claims Settlement Practices Act in your particular state. I think it's codified in every state except don't quote me and every state except don't quote me Arizona, maybe Don't quote me on that, but I think it's, you know, basically in 49 of the 50 states and then in all of the territories and whatever, because, like Guam has it, puerto Rico has it, blah, blah, blah. Anyway, the one thing that I do see and I do worry about a lot is the communication aspect. Communication with our insureds are so incredibly important, and I have written on LinkedIn many, many times about how, if you over-communicate with people yes, it's going to take more time, especially over-communicate up front then it won't be so bad and such a time suck towards the latter part of the claim process. So let's start talking about that.

Speaker 2: 9:16

One of the key things is with the Unfair Claim Settlement Practices Act, and I'm just probably going to call this the UCSPA, lmnop, sob XYZ. So one of the things that is so incredibly important is that communication, and I see this so often where, now that we have email and texts and things of that nature, the insured will text you, you will send a text via the system. So the system creates that. You know memory of it, because I always worry about you texting, you being the adjuster, texting the insured from your cell phone. It you know, even if you forwarded iter, texting the insured from your cell phone, even if you forwarded it over, took a screenshot and emailed it to yourself to put it in the claim file. That's just asking for trouble. Use the system, use the system.

Speaker 2: 10:18

The thing that I worry about is it is so fast. Communication is just boom, boom, boom, boom, boom, and in a lot of instances we don't pay attention to our emails and so when an email comes into you asking you a question, the UCSPA requires you to respond within quote, a reasonable end quote time. Now, what's a reasonable time? I don't know. A jury will know that. And do you want to get in front of a jury? Absolutely not. Um, you don't. So, um, you know you. You've seen some things that say, I don't know 72 hours. Some courts have even said, yeah, 30 days is okay. Some states will even say 15 business days, which is actually three weeks, which is a long time?

Speaker 2: 11:20

Some states say 15 calendar days, which is two weeks. But here's my thing. And, heather, you don't have to admit that this is you, but you can say it's for a friend. Let me ask you this question when you get that email from your boss, do? You really pay attention to it? I mean, or does your friend pay attention to it?

Speaker 3: 11:51

pay attention to it. I would say it's very difficult today in the way that communication has changed in society as a whole, right, everyone expects. The expectation of people today is what? Instantaneous response, yes, right, right. I think that that also feeds the fire. You can talk about the Unfair Claims Settlement Practices Act saying, ok, there are reasonable requirements of response, but most people's perception of a reasonable response today is very different than maybe it was five or even five years ago. Right, absolutely. We communicate in this like like constantly going world and and insurance isn't there. You know and, by the way, I'll back up and backtrack when you were talking about people like allowing people to text them to their personal phones. You know, there's this whole world of bring your own device to work and utilizing apps and everything. And then there's also this other world of you know you have a company-owned phone if you work for a company. All of that information is discoverable, folks.

Speaker 2: 13:03

Okay, absolutely, that was my point.

Speaker 3: 13:05

You know, yeah, like everything that is in that is fully discoverable and they can even take like your personal information as well. So if you talk on the side or you chat about things that might be perceived about you in a certain way, you don't want that to be flashed up on a screen in front of a jury today, especially in today's environment. But I always espouse to the philosophy when I was adjusting claims of document, document, document, document and make sure that whatever communication that I am having with that insured. Now I didn't live in the world of text messaging, just so you know. It was a few years ago when I handled claims, but not that long ago.

Speaker 2: 13:49

I didn't. I didn't either. I didn't either, but I did do emails.

Speaker 3: 13:54

Yeah, but I did do emails. But when I started in claims we had no capability to email people. You know that just wasn't done. You know that just wasn't done. But you have to read and acknowledge the content and make sure that you understand it before you respond to it.

Speaker 3: 14:16

And I guess that's just a cautionary tale for the way the world has gone with communication today, because we just fly with whatever's coming out of our brain at the moment, whatever's coming out of our brain at the moment and blah, blah, diarrhea of the mouth that we want to say because social media and texting and all of these technologies, they're fantastic, but they haven't enabled and unlocked and unleashed this capability to just like stream of consciousness Right and unfortunately, half the time. That doesn't make sense. Yes, and so you have to be very, very careful, especially when you work in those claims roles, to document and send back a response that says here's the things that we talked about in our conversation.

Speaker 2: 14:59

Absolutely. This is a very key point. I love that you've said this, because I'm currently working on a case right now and bless her heart, as we say in the South. You know, this is the adjuster. Bless her heart, bless her heart. What she would do is she would get an email, she would look at it and she would document the file, but it would say something like no response is necessary and I'm like, well, okay, maybe not. You know they weren't necessarily asking a question or whatever, and no, you don't need to do a thanks or you know, so that they would go you're welcome and then you have this loop thing going. You don't necessarily need that. But what I would like to see, of course, in your file notes, which is a whole different section of the unfair claims settlement practices act, but we're talking about communications what I would like to see is your summary of the notes, communications. What I would like to see is your summary of the notes.

Speaker 2: 16:08

However, when we're talking about this communication and you get this thing, like you were talking about, from the insured or the claimant or whomever, what I would do is and it happened to be something that that may be required a little bit more in-depth thing is a I would pick up the phone and and talk to them, because that's the best thing to do. I have seen so many and I know that a lot of people don't want to talk on the phone today, that we'll get to that later maybe but, um, you know, picking up the phone and actually explaining that. I've seen so many emails that go back and forth, back and forth, back and forth, when it would have solved, been solved by a five minute phone conversation rather than three days of emails and everybody getting frustrated. Beside the point, what I would usually do in this particular instance, what you're talking about, is I would hit, respond and I would say please see below, and then I would go into the claimant be the first claimant, the third, third, first party claimant or the third party claimant and go in and right where they, would you know, have their question what, what are you doing about? Blah, blah, blah? I would you know, hit, enter a few times, change the color of the font, and that's where I would respond and keep going down that way. So that way I have also ensured that I have made sure that I've responded to all of the questions in a reasonable time and if I don't know the question or if I don't know the answer, excuse me. If I don't know the answer, guys, here's. Don't know the answer? Excuse me if I don't know the answer, guys, here's a way to do this. Here's your helpful hint for today Use your Outlook calendar and set yourself a separate diary.

Speaker 2: 17:55

I know that your claims management system will have a diary system in it, you know, and the last thing you want to hear is someone telling you to set up a separate diary system. But trust me on this. Set up, on your Microsoft outlook or Google outlook, whatever you know, a separate diary system that says have I gotten the independent adjusters report back for Chantel Roberts claim? You know, and, and that sort of thing. And, of course, like, like, and I know because you work for a JS held, um, I, I know that engineers and experts do the Scotty technique, uh, which is and I want everybody here to do the Scotty technique, which is, if, if you can do the, the work, whatever the work is, in five days, you go, oh, I'm telling you, captain, it's going to take 10 days to do it. You know, that's my horrible Scottish accent. Uh, overestimate. And then you give it to them in much. Don't tell them five days, because they're going to be calling you in four.

Speaker 3: 19:12

Basically, but, yeah, but that's my, that's my thing, Give yourself the windows that you need and realize and I and I get that. That's a hard thing to gauge when you're brand new.

Speaker 2: 19:24

Yes.

Speaker 3: 19:26

Okay, but when you look at your workload, realize that the best thing you can do is make sure that the ball is in the insured's court, to use a sports analogy. Here, my philosophy was if I can make sure that I have given them the tools and the resources that they need to be able to send me the things that I need to do my job, everything is going to go much better. And then I'll backtrack to what you're talking about with a phone call. I get it. Folks, nobody likes talking on the phone. Today I have a.

Speaker 3: 20:09

I have a very close CPCU friend and she has all these memes about millennials being terrified of their phones ringing as well, because you, that those generations, grew up in a world where that their primary method of communication was typing and texting and digital right tone and your ability to inflect your voice can bring calm to a situation that may feel like it's going to get out of control, and tone is very, very subjective to an individual. In a written email yes, we, in the shortened like staccato way that people speak today in text message and in email as well, so take that to heart. If you need some skill building, talk to some people who worked in a world where most absolutely everything they did was over a telephone and how they talk to people. Sit down and have conversations regularly. Teach yourself the art of conversation, because you're going to need it in a claims adjuster job and it will make your life so much easier if you're just a good verbal communicator with people.

Speaker 2: 21:29

Absolutely. And this goes back to our communication aspect, communicating with people on a on a routine, regular basis. I have always told people expect your first conversation or setting up a claim file or whatever, to take an hour. And they go oh, my God, I'm like. I know, I know, but it's going to take an hour because at least 15 to 20 minutes is going to be spent talking to the insured and you need to outline every single thing that is going to happen. Step one I'm going to assign an appraiser or I'm going to come out and look at this. Step two I got to to assign an appraiser or I'm going to come out and look at this. Step two I got to write this thing up. You know, I also got a family and a kid that plays soccer, so it's not going to be tomorrow. You know and and remember, I and this is the example that I always use explain it like you're explaining it to your grandmother, and that is the way that you're going to remember, even if they're your age. Explain it to like you're going to explain it to your grandmother, because that way you will know to basically over-explain.

Speaker 2: 22:33

Um, and and the other thing about the communication. Um, there's two things about the communication that I wanted to mention, especially about the phone, and this I found particularly interesting, because I was always like, just pick up the phone, darn it, and everybody would say, yeah, but they won't take my phone call, nobody will take my phone call anymore. And I was like, well, that's just stupid, because if I've filed a claim, I'm going to answer some unknown phone call, you know whatever, because I don't know if that's the adjuster. However, one of the things that one of the vendors did for me one time wasn't a claim, but they sent me a text saying so-and-so is going to call you between these hours with the area code of blah, blah, blah, and so they didn't know, like, what the exact number was going to be. Or they didn't tell me what the number was going to be, and I'm like I love that. You know we could do that, as adjusters say hey, I'm your adjuster, I'm going to be calling you between these hours and this hour, or, you know, between nine and 10 AM on Wednesday. Area code number 913. Um, please be prepared for my phone call. If this is not a good time, let me know. Respond to this text or whatever, and that way you're not playing phone tag with these people or whatever.

Speaker 2: 23:57

My husband is a claims adjuster, as we know, and he has been trying for three weeks to try to get in touch with the insured. By the way, guys, don't try for three freaking weeks to get in touch with the insured. Send them a letter by this point and copy their agent. Anyway, beside the point, I have to keep my mouth shut because hi, honey, love you. He didn't watch this, um, you know. But anyway, there you go.

Speaker 2: 24:22

Um, okay, the other communication thing that I was going to tell you is If it's important, like a letter of declination or something to that effect, like a reservation of rights letter of declination, you need something really important, like, by goodness gracious, I need this. Write an actual letter. You can email the letter, attach it, you know, and then, in the body of the email, dear Mr and Mrs Insured, this is a reservation of rights letter which I've already called you and explained, or this is the letter of declination which I've already called you and explained. You know, yada, yada, yada. But here it is because, again, like, like you said, people want this instantaneously and then physically mail it. Because, again, like heather didn't, uh, uh, admit to her quote-unquote friend um doesn't necessarily pay attention to all the emails that she gets, and neither does your insured or the claimant.

Speaker 2: 25:32

100 and they do with mail.

Speaker 3: 25:36

Yeah, is that there are certain states that require that you send those types of things certified yes so you have a record of receipt if the individual has received it or not.

Speaker 3: 25:48

Me, I, you know. I always think it's like a great practice to make sure that you do send that, like at least signature mail or registered receipt, so that you have a record that this was received at this particular address, location on this date. That establishes a trail of evidence whenever you're trying to make sure that you have. Because again you get back to this communication piece, it can be viewed that you are failing in some of the aspects of the Unfair Claim Settlement Practices Act, and I cannot get that acronym in my head.

Speaker 2: 26:27

Oh, I can't either. I mean I can't either.

Speaker 3: 26:35

I can't either, but it can be viewed especially, and it can be utilized as an element for bad faith cases. If you're not making sure that your communications are arriving in the hands of the people they're supposed to arrive in, yeah, and so protect yourself, cya, and make sure that it's there in their hand.

Speaker 2: 26:53

Absolutely. I can't, I can't stress that enough. Okay, so I think we've beaten communication to death, you know. Yeah, the other one would be also to start off with your reasonable investigation. And again it talks about quote, unquote, reasonable and what is reasonable. You got to start it off again and the best thing I can do is is say let's all think about COVID.

Speaker 2: 27:23

Remember when we all were here in COVID and everybody was turning in business interruption claims and these insurers automatically started sending out these denials because they had virus exclusions or whatever, and there was a plethora of bad faith claims because the adjusters or the insurance companies didn't even send someone out to investigate that the stores or the restaurants or wherever had COVID and that's the reason why they were closed down.

Speaker 2: 27:58

As silly as that sounds, what you have to do as an adjuster is go hire your forensic hygienist or whatever, and and, and go out and have them do some testing and say, yep, no COVID here, and or whatever you, and have them do some testing and say, yeah, no covid here and or whatever. You've got to do that you also and I know again, you get 15 claims a day or whatever. You can't necessarily start that investigation quote, unquote as soon as possible. But you got to. You know there's no delaying the investigation. If you get some new information, you got to go kind of run down that rabbit hole too. You don't have to run down every rabbit hole, don't get me wrong. But you do have to do a reasonable investigation. You can't delay that.

Speaker 3: 28:50

Yeah, I think you have to be. You have to consider that it's like this little mystery every time that a claim comes in the door, turn it into your puzzle, basically.

Speaker 2: 29:02

Yes.

Speaker 3: 29:02

To uncover the parts and pieces of establishing or determining that there is not coverage for that loss, or if you're on the liability side, looking at it from the perspective of are we liable or are we not? You know, and what's the? You know the four steps of negligence that you have to look into and everything. And you cannot get into the mindset and this is a really big trap for adjusters. They get in the mindset just like folks did during covid uh, well, every claim is the same, because this is what they're claiming. Folks, every single claim is not the same. It doesn't, it doesn't matter, and that will get you in some trouble. Yes, start to slip your slip into that mindset of well, they're claiming the same facts a lot, so it has to be the exact same circumstance, right? Yes, and that can happen even outside of COVID circumstances, absolutely.

Speaker 2: 30:04

Oh, a fire is a fire is a fire or whatever. And you know, I actually say that's why I love being in claims is because you can have two fires. Two fires I mean side by side of the house or whatever, but they're going to be totally different. The insurance are different, the policies are different, the causes of loss are different. I just find it. That's why I find claims being fun personally, but you are absolutely right. I find claims being fun personally, but you are absolutely right.

Speaker 2: 30:38

We've got to start talking about the explaining the policy, which is again one of those unfair claims settlement practices. Actually we'll get to in just a second because we need to talk about that as well, but we do need to begin our investigation. Whatever the investigation is, you know. Whatever the investigation is, you know, asking for receipts, sending out an appraiser, or us going out there to photograph evidence, sending the car to a preferred vendor, if that's what the case is, getting an engineer out there so that we can figure out what's going on, what the cause of loss is, whatever, we have to do that within a reasonable time. What that reasonable time is, again look it up in your state, or I would, I would almost say 24, 48 hours, maybe 72, but you know that sort of thing. I don't. That sort of thing. I don't. I don't know if there's anything like that. Any list of of what a reasonable is per state, yeah.

Speaker 3: 31:41

It's very, very different state by state and of course you know there's there's like clocks that start ticking in certain states.

Speaker 2: 31:48

Oh, yeah, absolutely.

Speaker 3: 32:14

You know, once the insurer gets notice, that's when to cross it today. That's when you know you've got to activate yourself. You can't play this. Oh, I'm going to slow play it or I'm not going to investigate this. Absolutely Like. You got to feel like and I know most people today probably didn't even watch what was that the 60 minute show where that clock's going? Oh yeah, didn't even watch. What was that the 60 minute show where that clock's going? Oh yeah, hear that in your head, okay, because, yeah, that's, that's what's going to happen, is the time's going to go?

Speaker 2: 32:42

really really fast. And here's, here's the thing that I don't think young adjusters necessarily understand, although you and I are talking about. When we first get that claim, you need to start this the clock. There are multiple clocks going on in any one given claim. So let's say you first get a claim in, you need to immediately assign an independent adjuster, or your field adjuster or whatever, to do the inspection. When you get her report back and her estimate back and her photographs back, your clock starts ticking again to respond to that and to pay.

Speaker 2: 33:24

Because, look, paying what you know you owe again is a huge, huge, huge thing within the Unfair Claims Settlement Practices Act. You cannot delay payment, and that is probably where we're going to go into next, because as soon as you get an estimate in, if you know you owe it, you need to pay it. If that means you're writing 15 checks in one claim because you agree with these three lines but you don't agree with those seven, and, bit by bit by bit, everybody gets to prove those other seven or whatever, and then there's a supplement yada, yada, yada, and so you end up writing 15 checks. That's what you got to do, dude, dude, you cannot hold back those three lines of covered loss just because you're trying to figure out the other seven lines.

Speaker 3: 34:23

You know and then the other side of that is is don't fear the reservation or rights letter oh god, yes, please, everybody does and it's because nobody wants to have the conversation about it.

Speaker 3: 34:34

You know, I will say, like when I started in claims handling, I was like, oh my gosh, I got to tell these people I'm going to send them this creepy, scary letter that's got all this strong language in it. But I got into this flow of hey look, we need some more time to conduct our investigation. We need some more time to conduct our investigation and because of legislation and laws, you know, we're bound by certain requirements. To make sure you understand that.

Speaker 3: 35:07

That was my spiel that I would get of a reservation of rights letter and then I would say this letter is going to have some language in it that feels like very strong and different, but it is basically saying that we're not giving up any of our rights as your insurer to deny this claim based upon policy provisions, but you're also not giving up your rights insured here by us sending you this letter. Make sure you have that. They understand that. That's like that two-way communication piece and then it goes over and they're like, okay, it's fine and it's all going to be okay. So don't fear your reservation or rights letters if you've got to have a little bit more of a protracted investigation.

Speaker 2: 35:50

Yes. So let's talk about that. I love that because you can't again tying that into the payment aspect. You can't delay or refuse payment without proper justification. So if you feel like, okay, I've gotten this 10 itemized line estimate or whatever, or let's say it's contents, and the insurer has sent you like 10 lines of contents and you can see from the photographs like three of them are covered in like seven of them we can't figure out yet, you can send that reservation of rights letter. And what I would do, of course again is I would pick up the phone and call them and go, hey, look, here's the deal, kind of like what you did. I'm going to send you what's called a reservation of rights letter. I'm also going to send you the partial payment because I can agree to this part.

Speaker 2: 36:42

I just don't know about this part. So I'm going to ask you for information about these things here and basically all I'm saying is I kind of disagree, I can't figure out. If there's coverage yet for those seven things, I'm not denying it. It will look like a denial letter. It will, but it's not, and it'll look big and scary and all that. I'm going to send it via email and it'll look big and scary and all that. I'm going to send it via email. I'm going to send it very via regular mail, just FYI, you know. And then when you get it, read it and call me back if you have any questions.

Speaker 2: 37:24

And because part again, a huge part, of the unfair claim settlement practices act, or if you just want to call it bad, or if you just want to call it bad faith, if you just want to call it bad faith is that in all of the policy or not the policy language, but in all of the regulations it specifically states that, quote insurers shall not fail to settle first-party claims on the basis of the responsibility oh wait, that's another one but delaying or refusing payment without proper justification and your denial must be in written form. Well, we're not denying it yet, but we are saying you know, we don't know about this, and that is what a reservation of rights letter is. It's not stop being scared of it, please. And and I cannot tell you the amount of claims I have seen as an expert witness where I have told the defense attorney y'all should have sent out a reservation of rights letter about this years ago, millennia ago, or whatever. So, yes, letters are important and again, I know we just talked about communication, but do those letters, attach it and also mail it, because, again, we're not necessarily paying attention to emails. Don't necessarily put this in a body of a email. Snail mail is perfect, okay.

Speaker 2: 38:57

The one that I actually started to read and I have seen this so many times is when insurers shall not fail to settle first party claims on the basis that the responsibility for payment should be assumed by others. And basically what that says is the insured has called you as the insurance company and said, hey, and this happens in auto like all the time hey, I got rear ended, I want to file a claim and the insurance adjuster is like, no, I'm not going to do anything because it's so-and-so's fault. That is bad faith. Because, again, right then, and there you know, you as the insurance company, because the adjuster is a representative of the insurance company, knows about the claim, you are a representative of the claim. The clock starts ticking. You got to start investigating that loss.

Speaker 3: 39:53

That's right. You have a fiduciary responsibility in that moment right, yep, you have a contract with that insured that you must meet Yep. It is their choice if they decide to pursue that via the other carrier or not. Right To make the choice about that. So that's that whole aleatory contract folks. Yeah, absolutely.

Speaker 2: 40:19

You got to investigate it. I know you don't want to because you got like 15 billion other claimants or whatever to do, but you got to investigate it, start your investigation and then do a subrogation that this is, this is what the premium is for, this is what the insured paid for. Sorry, sorry, charlie, but it goes back to that whole thing Like you got to pay when you know you owe it. So as soon as you get an estimate in, you know, look it over, apply it to coverage and go, yep, I can pay that. No, I can't. Here's the flip side of that. If you get an estimate and obviously it's not related, again you need to send a declination letter about those particular things. It would be a partial declination letter, don't get me wrong. It's not a whole thing. But you're going to say okay, on line 10, you said you wanted to replace the carpet with tile. You know we're only going to repair what you had damaged. You didn't have tile, so I'm I'm only going to pay what it would take to repair your carpet or replace your carpet. I'm not going to pay this extra $15 to put in tile or whatever. That's what you need to do. You can't ignore it, guys, you cannot ignore that. Yeah, oh, that's the. Not accepting claims fairly once liability is reasonably clear. Multiple payments, yeah.

Speaker 2: 41:56

The other thing that I see all the time is the when it comes to estimates and I don't want to call any particular adjusters out but y'all probably, I mean I, but y'all probably, I mean I, yeah, yeah, anyway, um, offering substantially less than what the insured would ultimately get in a court of law. This is a tricky one and of course, I haven't got. We, we're not going over every single one of these unfair settlement practice acts. I'm just hitting the highlights of that I normally see in litigation or whatever. And this is something that gets caught up a bit because the insured will have an adjuster who has written up an estimate that is, I don't know, five times more than what the insurer's estimate is.

Speaker 2: 42:51

And recognize, guys, that I'm not always on the insurer's side. Sometimes I get hired by the policyholder and whether that estimate the policyholder's estimate, is legitimate or not is not really what I'm looking at. I'm looking at, you know, good Faith Claims Handling act. Did they, you know, settle for the correct amount? You know, did they respond in time? Did they begin their investigation in time? Did they communicate Blah, blah blah. That's what I'm looking at. So basically, the rule is don't lowball. Yeah, yeah.

Speaker 3: 43:32

You know you have to. You have to take in all the evidence that you have of a claim file and consider every piece of that evidence, and I get it. Some of the time adjusters miss damage. It happens routinely. They are human beings, but that's why it's called an estimate folks. Okay, and it's okay to tell a policyholder this is my estimate of the damages when you're trying to make sure that you're establishing those good communication guidelines with the policyholder. This is my estimate of damage. If your contractor's estimate comes in more than this, then you're please contact me so I have a moment to visit with the contractor. Maybe we need to meet back out there again to talk about the damages. But don't just expect automatically that your estimate is golden every single time because it's an estimate folks.

Speaker 2: 44:29

Exactly. I love that and I would even add if you want to again avoid having multiple issues, when you send out your appraiser or your adjuster or you go out there to investigate and write the estimate yourself, ask the insured if they have a contractor already and have that contractor out there, so that y'all can arrive at an agreed scope. And again recognize that, like you said, once they tear off the roof or something, more damage may be discovered, and recognize the fact that there are states that say Texas is a good example. If you have three layers of shingles insurance company, you are going to tear down all the way down to the you know, baseboards or whatever, to sorry, the iron claw, who is my cat, is over here just meowing, just like and just like. Pay attention to me. So yes, the Iron.

Speaker 2: 45:44

Claw is. That's his name. You can't just say the Iron Claw, but you've got to, anyway, yeah, down to the roofing membrane and stuff. You've got to go all the way down to the roofing membrane and of course you're going to know this because you're in your own states or whatever states that you happen to be working on. Back, you need to again text the insured going to be calling. You call the insured and say this is the estimate that I've gotten, this is the estimate that I've written. Do you have a pen and paper? I want to. You know, I'm going to send you a letter, but I want you to see. You know, yada, yada, yada and and go over it. You know that way, one of the things that I would mention too, which I think is a very good point.

Speaker 2: 46:38

I'm currently writing an article about public adjusters and a little bit about why insurance companies' estimates are a little bit different than public adjusters.

Speaker 2: 46:49

We have to again, part of the good faith claims handling practices explain coverage to the insured. Right, and I know I always forgot, consistently forgot to discuss debris removal. Um, you know the overhead, not the overhead, but the um ordinance and law coverages, you know, and all that kind of the things that they would need to pay themselves and then get reimbursed for. And I've seen it now a lot where these things aren't in insurance companies estimates because they have to be reimbursed, but they would be in a public adjusters estimates and I think it might be a really good idea for us as insurance companies to put debris removal TBD because it shows that we are going to consider it, but you know it doesn't look like we're totally ignoring it, and that would help the insured understand again why our estimates may be different from someone else's, like the contractors, like the public adjusters, or well, I think it behooves you as an adjuster today to understand line item pricing, especially on that property damage side.

Speaker 3: 48:20

You have to understand line item pricing and what are the components of that price. Because if you cannot have an educated discussion about what the components of that price are, then you're going to get eaten alive by not knowing what your estimate is actually for. And I get that that as a desk adjuster. A lot of times that's really difficult because you weren't the person that sat out there and looked at it and and put your hands on it and smelled the mold or saw the water damage or saw the hail all over the roof yourself. But put yourself in a place where you're educating yourself about how those estimates are broken down so that you can have educated conversations, because most of your estimating pricing platforms are going to include an element of debris removal in the line item pricing.

Speaker 3: 49:07

It just depends on the loss situation. That's why it's every claim is different, folks, folks. It depends on the law situation as to whether or not that debris removal coverage is incurred, because it's bigger than what you know. The line item pricing like like build-in price has with it. So, um, it's been years since I thought about that. So that just brought up such great memories of line item pricing for me memories.

Speaker 2: 49:35

Who knew that we were going to be doing like a whole musical episode of the art of adjusting. I mean, bill and I never sing. This is great, yeah. Um, going back to your line item issues again and tying this into communications, guys, I can't. I mean, obviously, you hear me talk about communications over and over and over and over again. But Louisiana just passed a law. Why do we have to pass a freaking law to do our jobs?

Speaker 2: 50:15

But what it said was and I think it starts July 1st 2026, or is something to the effect of if you're going to remove something in an estimate, you need to explain why. Well, duh, we should have been doing that regardless, and you know what it starts from. Is that 60 minutes? You said 60 minutes and that's immediately where I thought you were going to go with it. Is that 60 minutes video, or expose in Florida where there was an insurer who was removing from the cat adjusters estimate. Now here's I said this on LinkedIn and it got quite a bit of traction and I didn't really think it would. But what I said was you know, I get, I get the point, but what 60 minutes failed to explore. And it's our insurance company's fault, because we never talk, because we listen to corporate attorneys, which is, you know, neither here nor there, but we never explain ourselves and that's part of the problem.

Speaker 2: 51:29

There could be any number of reasons why they removed items. They weren't covered. You know, things fell beneath the deductible, I don't. I don't know. Obviously, if it fell beneath the deductible it wouldn't, it would still appear on the estimate. But regardless, most of it would be it's not covered.

Speaker 2: 51:52

But you should still send a letter, a declination letter. I would recommend first sending a reservation of rights letter. In fact, I believe Texas again I mentioned Texas before but I believe Texas requires you to send a ROR before sending your declination of coverage letter. I always recommend sending a reservation of rights letter, coverage first, because it's kind of like closing the door but opening the window. We're saying this part may, may, may not be covered, but let me know. So I'm going to remove those lines and here's your check for the partial payment.

Speaker 2: 52:30

Because, again, remember, we got to pay what we know we owe when we know we owe it. We can't hold back these checks. We got to pay what we know we owe when we know we owe it. We can't hold back these checks. So you see how all of these are tying in together. But why do we got to make law about this? Why do we got to be? I know why. But I mean, seriously, don't be, don't be silly guys, don't. Don't have the states start making laws about these sorts of things. That's crazy. Just we should do the right things.

Speaker 3: 53:00

The legislature is definitely in some states, is definitely responding to the marketplace cry at the moment. And again I go back to Unfair Claims Settlement Practices Act protects not only the insured, it protects the insurer as well. Yes, it's supposed to like create that like rules of the game.

Speaker 3: 53:22

That and I don't want to call an insurance claim a game, but it really is you know there's rules associated with it and there's rules that the insured has to abide by in the conditions of that policy, and there's rules that the insurer has to abide by. And the insurer's rules are going to be really hefty. Because? Why? Because we wrote the contract.

Speaker 2: 53:44

Exactly. I'm so. I'm so glad that you mentioned that, because I had written somewhere in some article or something that you know in the policy it has all the duties that the insured has to do, you know. And then I asked the question where is the insurance company's duties? Because that's nowhere in the policy except we will pay if you do this, this and this. You know, and it's not excluded. I mean, that's nowhere in the. You know where it is. It's codified in law. That's where it is.

Speaker 2: 54:18

That's where it is, and that's what we're talking about, Like technically, if you're not responding within a quote reasonable time or you're not sending out these reservation of rights letters or you're not paying what you know you owe, technically, you're breaking the law.

Speaker 2: 54:32

Are you going to go to jail? No, are you going to get a bad faith claim? Probably, you know, I mean, and then I get hired and look, I'm just really tired, I just want to do podcasts and like write articles and stuff. So, um, I don't know why are y'all making me work?

Speaker 3: 54:52

folks like extra contractual suits are no picnic, All right and and they can make. They can make you feel awful at times, especially when you're the person that has to sit on the other side of that table and in a deposition and defend someone else's actions. Maybe even if it wasn't your claim file that you handled from beginning to end, Right and, and having sat in that hot seat, I can tell you 100% it made me a much better adjuster because I learned all I knew, like all of these things that could get other people in a bad place in handling a claim file. My best advice for you, for anybody, is that go into your claim file handling as if that might happen, yeah.

Speaker 3: 55:48

And I don't care how small the file is, I don't care how tiny it is. If you have that mindset of this, this is the result that could happen and granted, I get it like percentage wise, it's really low the percentage that actually end up going to like full-on litigation most of the time. I understand that. But if you, if you work your file with the mindset that it could don't be adversarial because of that, no, but make sure that you are handling that file with all of the unfair claim settlement practices act in mind and, as we've said, 1 billion times 1 billion dollars communicate, communicate, communicate, communicate verbally and writing.

Speaker 2: 56:33

Yes.

Speaker 3: 56:34

And then communicate again.

Speaker 2: 56:36

Absolutely, absolutely. And I know that it feels like that would really take away a lot of time, but I have told adjusters time and time again look, if you're setting up your claim and it takes an hour, I guarantee you it's going to save you an hour and a half on the end. Yep know, I guarantee you, our next one is actually our next podcast is actually going to be a little bit more of this bad faith examples. And all that because what I thought we would do it's going to air on September 11th.

Speaker 2: 57:15

This one is airing on August 28th but I thought what we would do is maybe talk about the myth of bad faith and, like the boogeyman of bad faith, like what it is, what it's not, because we throw around this word and everything. So I thought we might, you know, maybe talk about what it is and what it's not. Uh, and, and you know, go, go, go from there and and see what's fair, what, because, hey, you know, just because people are demanding that, it doesn't mean that. Well, you know, they necessarily get it. The policy might not respond to that.

Speaker 3: 57:58

Yeah, and and again.

Speaker 3: 58:00

Bad faith isn't anything like it sounds so scary, it sounds like the sounds like the boogeyman, monster closet the boogeyman Jason, you know, michael Myers, it sounds like all those kinds of things that I know it's not Halloween yet, but I'm a fall person, so so, yeah it, you have to again. No, don't be afraid of it, but also realize that it gets asserted a lot of times and it's really not there because there's conditions for establishing it. But protect yourself in the instance of that as best as you can by doing all these things that we've talked about today, absolutely.

Speaker 2: 58:39

Absolutely so. We, I think I think we've basically beaten everything to death about you know, and again, go to your, just Google, your state, unfair claim settlement practices, act and see what your rules are. You know, those are your rules. That's what you have to do as adjusters to settle your claims without getting in trouble. Um, yeah, I think that's it. Uh, we will see y'all in two weeks. Heather, thank you for being a co-host for uh. For now, five more. I know you're like counting down like oh, my gosh, Uh, and, and enjoy joining me in this musical edition of the art of adjusting.

Speaker 3: 59:26

Tomorrow.

Speaker 2: 59:27

Tomorrow, oh, I guess it would be next week, next week, okay, okay, Our, our, our, our viewership is going to plummet. See you later. Bye.

Speaker 1: 59:43

Thanks for joining us on the art of adjusting podcast, where we talk about life as an insurance adjuster.

Speaker 2: 59:49

If you enjoyed this podcast or this episode, please give us five stars and a review. It does help the algorithm pick us up.

Speaker 1: 59:57

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Speaker 2: 1:00:19

In the meantime, you can contact me at theartofadjustingcom for consulting and training purposes.