Casualty claims professionals face the double whammy of a litigious society and potentially volatile claim outcomes, making it more important than ever for them to hone their skills and improve the techniques they use to achieve favorable outcomes. Focusing on optimal claim handling techniques will set the stage for success.

Casualty claims require that the claims professional consider three major areas: coverage, liability, and damages. Each of these issues requires investigation, evaluation of the findings, and negotiation to a fair and equitable outcome. 

Examination

Investigation is a skill that will set the adjuster down the correct path toward claim resolution. Starting with a review of the policy for coverage confirmation, the claims professional will first want to understand what is covered, the extent of the coverage, and to identify the insured person or entity. Coverage review will also reveal any lapses in coverage that could prove problematic later as the investigation into liability and damages progresses. Investigation of the facts is conducted to determine the extent of the liability of the insured and other parties to the occurrence. Similar to a journalist, a claims professional will want to determine the “who,” “what” “where,” “when,” “how,” and “why” of the situation. The claims practitioner can uncover this information in a number of ways, such as:

• Taking statements from the involved parties.
• Interviewing officials, for example, police officers, and fire personnel.
• Examining the scene of the accident, either in person or through the use of Google Maps.
• Inspecting damaged property, machinery, or buildings.

The claims professional will want to ask questions such as, “Who were the individuals involved in the accident?” and “Who were the witnesses?” Lines of questioning may also resemble the following:

• What occurred prior to, during, and after the accident? What contributed to the accident, and what damage is covered by the policy?
• Where did the accident happen?  Where are the individuals or official reports that can provide insight into the facts?
• When did the accident occur? When and to whom was a report made?  When the accident occurred, what were the weather conditions? When should the investigation be conducted—immediately or some later time?
• How did the damage occur?
• Why did the accident happen? Was the proximate cause due to the insured's negligence or that of some other person? 

Coaxing answers to these questions from the involved parties will ensure that the claims professional uncovers the facts and can establish the truth about the details of the accident. When there are no parties available to question—such as in the case of a multiple fatality accident—the adjuster will use scientific means by investigating how the damages may have occurred based on the physical evidence available. 

It is commonly accepted that most investigation is conducted via phone, mail, or internet. However, each of these technologies limits the scope of perception.  Humans learn from all five senses, so using “distance” technologies may impede an investigation or even result in drawing incorrect conclusions. Because people learn from what they hear, see, smell, taste, and touch, in-person investigation may reveal information that could not have been uncovered via phone, mail, or e-mail. For instance, when investigating a claim alleging food contamination, the medical report and claimant's statement may all support a finding of food poisoning, confirmed by receipts from the insured's restaurant. However, a visit to the claimant's home would allow the claims professional to see that it is dirty and ill-kept, and even smell foul odors. In that instance, the food poisoning most likely came from the claimant's own kitchen, not the insured's. 

Technology has streamlined investigation, but is also limited and not appropriate in all situations. Investigation is conducted in a logical, systematic manner. It begins with an inquiry into the facts of the accident. Those facts must be verified. As new evidence is uncovered it must be compared to the known facts to determine if additional investigation is necessary. 

Generally, when a loss is reported, the claims professional has two types of facts– those that are known, and those that are unknown. The initial report will include the insured's version of the accident details—what occurred and why—these are the known facts. The claims professional must remember that there are also unknown facts—the other party's version of the accident, the amount of damages suffered by the other party, and the amount of the property damage. Independent witnesses, or individuals not involved in the accident itself, are also owners of unknown facts that the claims professional must uncover and move into the “known fact” column.

Adjusters use specific techniques for verifying facts as they become known.  These techniques include:
 

Witness statements may corroborate the facts already obtained, or be in opposition to what the claims professional has already uncovered. The adjuster will want to corroborate the witness' statement by comparing what is said against the physical evidence. Do the tire marks support the witness' testimony regarding the speed of the vehicles or where the accident occurred in the intersection? In the verification process, it's important to remember that people are usually poor judges of time and distance and a witness should not be discredited entirely because of being a poor judge.

Experts are used to provide specific information. Because they have particular skills, experience, and knowledge, they can examine evidence and express their opinion which will guide the claims professional.

Hypothetical questions are often used in medical claims, but can be appropriate in other situations as well. The claims professional will describe assumed facts and inquire whether the accident or injury could have resulted. This is done routinely in medical or bodily injury claims when the claims practitioner asks the physician whether the treatment being obtained is appropriate for the type of injury sustained.
Examination and/or testing an object is usually carried out by experts such as engineers, who are schooled in determining cause of loss. This can be done by examining and analyzing a failed product, or tests can be conducted on a similar product to determine how it reacts under the same or similar circumstances. Food contamination claims routinely require use of this technique to examine the allegedly contaminated food and determine if it contains foreign objects or unacceptable levels of toxins.

On-scene investigation and/or on-site tests take place where the accident occurred, preferably under the same general conditions that were present when the accident happened. Engineers are usually engaged to conduct these tests at the accident scene and may be asked to provide a plat of the area, note the physical evidence available, and express an opinion as to how the accident occurred. Even accidents lacking witnesses may benefit from this type of analysis, for instance, a premises of a slip-and-fall case may require an investigation into the type of flooring or wax coating that was used to determine the extent of friction the claimant may have experienced.

Medical examination is often referred to as an independent medical examination (IME). This is useful when the type of treatment, diagnosis, disability, or extent of injury is in question. Prior to litigation, a claimant is not required to undergo an IME. However, if it would be  conducive to settling the claim without litigation, an IME may be beneficial to establish the extent of the bodily injury, need for future medical treatment, and permanency of the injury. When using this technique, the claims professional will want to consider when the examination should be conducted, the extent of the exam, carefully select the medical examiner, and decide what type of report should be submitted.

Physicians used for IME's should be able to comment on their findings, the causal relationship of the accident to the injury and the diagnosis to the treatment, prognosis, and overall opinion as to the course of the treatment, its appropriateness, and what additional treatment is necessary.

Disability can be verified in a number of ways, such as through activity checks in which the claims professional scans the neighborhood in which the claimant resides inquiring as to the claimant's disability or physical condition; surveillance; and videotapes of the activities undertaken by the claimant.

Evaluation
As the investigation progresses, the claims professional will begin to develop a theory of defense which serves to establish a basis for any remaining investigation. 

The theory of defense will be based on the testimony of fact witnesses, expert witness opinions, and the physical evidence.  The theory of defense may change as new facts are uncovered or new information comes to light.  A successful tort action requires that the insured had notice, that there was a breach of ordinary or professional care, and that the breach was the proximate cause of the damages, and that actual damages were sustained. 

The claims professional will continually consider and evaluate the evidence in light of the theory of defense to make sure it is supported by the facts. As more facts become known, it is necessary to evaluate those facts and begin to make decisions about the negligence of the insured and the extent of that negligence, if any. To preclude a successful action in tort, the claims professional will need to prove that the insured was not negligent, that the claimant was negligent, and that the insured did everything possible to avoid the accident. The evidence must be evaluated  as carefully and as objectively as possible.

Careful analysis of the strength of the defense will assist the adjuster in determining whether the case should be settled or whether an aggressive defense should be raised against the allegations of the claimant.

To avoid the expense and unknown outcome of a full blown trial, many casualty claims professionals utilize a number of alternative resolution strategies such as arbitration or mediation to attempt to conclude the case at a reduced expense and in less time. 

There are times when it is the claims professional's preference that a case proceed to trial. Perhaps the plaintiff has been unreasonable, perhaps there is no liability on the part of the insured, perhaps there is an indication of fraud. For any one of these or other reasons, the result of the adjuster's careful evaluation is that the case supports a trial on either the facts or on the damages issue. 

The decision carries import as trials are not inexpensive propositions.  Court costs and attorney's fees can be extremely high, particularly in complex cases. Jury verdicts are never a sure thing and often seem arbitrary. Successful litigation requires careful planning and development of a strategic defense of the case. 

Negotiation
Upon the assignment of a new case, the claims professional will begin preparing a plan for the initial investigation and immediate work that is required while at the same time keeping in mind that the case may not settle and will be one to adjudicate. Skilled negotiators work the same way. They focus on the here and now, but take steps that will lead to resolution of differences as quickly as possible. The claims professional will handle every case as if it will end in trial, while at the same time establishing a relationship with the injured party that will support amicable resolution of the case without the adversity of trial.

Negotiation skills may be necessary in determining coverage and are required in discussions with the underwriter, the agent or broker, and the insured. 

Working with the claimant to resolve the issues of liability and damages require the ability to discuss the facts objectively, the possession of strong interpersonal skills in order to obtain the trust of the other party, and a sense of equity in reaching an agreement.

Keeping the focus on the goal of case closure will serve as a compass for the claims professional. Petty remarks, irrelevant facts, misrepresentation of the facts, and distrust are barriers to successful negotiation that should be avoided. 

Core Competencies
Casualty claims professionals face a number of challenges. Meeting those challenges and obtaining good outcomes and prompt closure require adjusters to continually improve their skills. It will be necessary for a claims professional to undertake career-long learning to develop competencies, such as:

• A good understanding of the law
• Being a good student of human behavior
• Good communication skills
• Excellent interpersonal skills
• A fundamental knowledge of medicine and anatomy
• The ability to conduct effective investigations
• A basic understanding of construction and how machines work
• Time management skills
• Independence as a self-starter

Casualty claims professionals will also want to develop certain characteristics that will ensure their success, such as:

• Being a person of integrity
• Expanding their knowledge
• Empathy
• A positive attitude
• A sense of inquisitiveness
• Develop a sense of equity
• Be disciplined
• Be able to embrace change
• Become a continuous learner
• Learn to analyze situations and evidence objectively
• Have good self-esteem
• Develop conflict resolution skills
• Be a problem solver
• Be decisive.

These competencies and characteristics will assist the claims practitioner in meeting any challenge. Developing good claim-handling techniques will ensure that the casualty claims professional is successful in reaching amicable and equitable closure of cases that have been assigned.