ocaa news jan 2015 24 pg - oregon casualty adjusters …oregoncasualtyadjusters.org/articles/ocaa...

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January 2015 www.oregoncasualtyadjusters.org | PO Box 87 Dexter, OR 97431 Claims Adjusters Association Oregon Providing informational and educational resources to the Insurance Claim Professional since 1935 Case Study Insured’s Ability to Avoid Payment of Insured’s Attorney Fees — See page 3 Message from OCAA President Tammi McEnaney, Liberty Mutual Next OCAA Meeting is January 13, 2015 See page 2 for time, location & other details NEWS from Around the Web — See page 9 Medical Notes — See page 5 The Insurance Claims Adjuster’s ‘Black Box’ — See page 13 Claims Ethics — See page 15 Adjusters to the Rescue: Trash Can Still Be Treasure, When Properly Restored — See page 19 Visit us online at www.oregoncasualtyadjusters.org I hope everyone had a great Holiday Season and are now looking forward to the New Year! I want to thank all who attended the Holiday Party and do- nated toys. It was a great turn out. A big shout out to STAR for sponsoring the event. I would also like to give a shout out to Past President Erica McDaniel for coordinating the event. As we start 2015 I am looking forward to a great year for the organization. With the changes already put into place, I am certain there will be more exciting things to come. I again, would really like to see you reach out to as many adjuster’s as possible to introduce them to the organization and encourage them to become members. We are still looking for Board Members so please reach out to myself or another Board Member if you or someone you know may be interested. See you at our next meeting, January 13. Happy New Year!

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Page 1: OCAA News Jan 2015 24 pg - Oregon Casualty Adjusters …oregoncasualtyadjusters.org/articles/OCAA News Jan 2015.pdf · 2015-01-05 · OCAA — January 2015 From the desk of Jeff Eberhard:

January 2015 www.oregoncasualtyadjusters.org | PO Box 87 • Dexter, OR 97431

Claims

Adjusters

Association

Oregon Providing

informational and educational resources to the

Insurance Claim Professional since 1935

Case Study

Insured’s Ability to Avoid Payment of Insured’s Attorney Fees — See page 3

Message from OCAA President Tammi McEnaney, Liberty Mutual

Next OCAA Meeting is January 13, 2015

See page 2 for time, location & other details

NEWS from Around the Web

— See page 9

Medical Notes — See page 5

The Insurance Claims Adjuster’s ‘Black Box’

— See page 13

Claims Ethics — See page 15

Adjusters to the Rescue: Trash Can Still Be Treasure, When Properly Restored

— See page 19

Visit us online at www.oregoncasualtyadjusters.org

I hope everyone had a great Holiday Season and are now looking forward to the New Year!

I want to thank all who attended the Holiday Party and do-nated toys. It was a great turn out. A big shout out to STAR for sponsoring the event. I would also like to give a shout out to Past President Erica McDaniel for coordinating the event.

As we start 2015 I am looking forward to a great year for the organization. With the changes already put into place, I am certain there will be more exciting things to come. I again, would really like to see you reach out to as many adjuster’s as possible to introduce them to the organization and encourage them to become members.

We are still looking for Board Members so please reach out to myself or another Board Member if you or someone you know may be interested.

See you at our next meeting, January 13.

Happy New Year!

Page 2: OCAA News Jan 2015 24 pg - Oregon Casualty Adjusters …oregoncasualtyadjusters.org/articles/OCAA News Jan 2015.pdf · 2015-01-05 · OCAA — January 2015 From the desk of Jeff Eberhard:

OCAA — January 2015 - 2 -

Time 11:30am to 1:00pm Location Old Spaghetti Factory 715 SW Bancroft St, PDX Menu Choices $15 Chicken Marsala, Spaghetti w/Mizithra Cheese & Browned Butter, or Chicken Caesar Salad Checks, cash or credit card accepted RSVP Requested www.oregoncasualtyadjusters.org

This newsletter is a publication of the Oregon Casualty Adjusters Association It is produced and distributed monthly by

Alquemie Publishing Ink (541) 937-2611 www.alquemiepublishing.com

Mail correspondence to: PO Box 87, Dexter, Oregon 97431

Fax to: (541) 937-4286 Email to: [email protected] or [email protected]

OCAA Vital Statistics 2014-15 PO Box 87, Dexter, OR 97431 Website: www.oregoncasualtyadjusters.org Email: [email protected]

BOWLING TAMMI MCENANEY, 503/736-8356 BUDGET & FINANCE COMMITTEE POSITION OPEN CONSTITUTION & BYLAWS PAST PRES. & CHAIR SPUNKY GRAY, 800/788-3933 PAST PRES. RON GRAY EMPLOYMENT KAYLA BEWERSDORFF, 503/736-8335 [email protected] GOLF PAST PRES. MARK JOHNSON, 503/565-2833 PAST PRES. MIKE MEADOWS, 503/736-7802 MEMBERSHIP PAST PRES. PATTY FERGUSON, 800/242-2923 X2551 MEETING PROGRAM & SPEAKERS TREVOR ARNOLD, 503/505-7534 [email protected] NEWSLETTER, SYMPOSIUM & WEBSITE COORDINATOR BARB TYLER, ALQUEMIE PUBLISHING 541/937-2611, [email protected] PARLIMENTARIAN PAST PRES. RON GRAY, 855/426-8898 SCHOLARSHIP KAYLA BEWERSDORFF, 503/736-8335 SYMPOSIUM TREVOR ARNOLD, 503/505-7534

FAIR USE NOTICE: This publication contains copyrighted material the use of which has not always been specifically authorized by the copyright owner. News and informational articles posted here are for

the non-profit purposes of education and news reporting. We believe this constitutes a 'fair use' of any such copyrighted material as provided for in 17 U.S.C § 107.

PRESIDENT TAMMI MCENANEY LIBERTY MUTUAL 503/736-8356 [email protected]

PRESIDENT-ELECT TREVOR ARNOLD MCLARENS 503/505-7534 [email protected]

TREASURER SEAN MCGUIRE LIBERTY MUTUAL 503/736-8357 [email protected]

SECRETARY KAYLA BEWERSDORFF LIBERTY MUTUAL 503/736-8335 [email protected]

IMMEDIATE PAST PRESIDENT ERICA MCDANIEL LIBERTY MUTUAL 503/736-8428 [email protected]

Standing Committees

Who will take home the pot?

YOU MUST BE PRESENT TO WIN!

At each monthly meeting someone could be

the lucky winner! Will you be present to

win at the January meeting?

Up for grabs in January: $100

No Winner in December

Crying Corner Jennifer Maks, Spunky Gray, Brian Driscoll, Sarah Hunt, Shawna Arndorfer

Featured Topic: Evidence Based Chiropractic Treatment of

Whiplash Associated Disorders with Charles Simpson

of Oregon Medical Evaluations

What better way to enjoy a meeting than to bring a friend!

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Barb Tyler (541) 937·2611

Fax: (541) 937-4286 [email protected]

PO Box 87, Dexter, Oregon 97431 WWW.ALQUEMIEPUBLISHING.COM

Newsletter Publishing • Executive Assistance • Event Planning Website Development/Maintenance and more!

Next OCAA Meeting

January 13, 2015

Page 3: OCAA News Jan 2015 24 pg - Oregon Casualty Adjusters …oregoncasualtyadjusters.org/articles/OCAA News Jan 2015.pdf · 2015-01-05 · OCAA — January 2015 From the desk of Jeff Eberhard:

OCAA — January 2015

From the desk of Jeff Eberhard: Can an insur-ance provider who has failed to pay a claim within six months after the proof of loss still avoid paying attorney fees under ORS 742.061(1)?

Claims Pointer: Yes, by paying the full amount sought by the insured before the court issues a money judgment. It is well established that an in-surer cannot defeat an attorney fee claim by filing an Offer to Allow Judgment more than six months after statutory proof of loss. However, under the Oregon Court of Appeals’ decision in Triangle Holdings, II, LLC v. Stewart Title Guaranty Co., in order for an insured to recover its attorney fees un-der ORS 742.061(1), the insured must have a “recovery”—meaning a money judgment—issued by the court. If the insurer pays the full amount claimed before judgment is entered, the insurer does not have to pay any amount in attorney’s fees under ORS 742.061(1).

Triangle Holdings, II, LLC, v. Stewart Title Guar-anty Co., --- P.3d --- (Or. App. Oct. 22, 2014).

The plaintiff in this case, Triangle Holdings, II, LLC (“Triangle”), a private lender, loaned $210,000 to a builder and received a trust deed to certain real property. Triangle then obtained a title insurance policy from defendant Stewart Title Guaranty Co. (“Stewart”) to insure against priority issues associated with the property. In May 2010, Triangle learned that several construction liens had been placed on the property. After notifying Stew-art of the liens, Triangle paid the liens itself. It then sought reimbursement from Stewart. On May 10, 2011, Stewart agreed to reimburse Triangle upon documentation of the payment.

- 3 -

To submit an article to this publication contact Barb Tyler at [email protected] or 541/937-2611. Length of the article is not as

important as its content, which should be educational in nature.

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Four weeks later, on June 6, 2011, Triangle sent Stewart the requested documentation. Two weeks later, on June 20, 2011, Stewart informed Triangle that it had ordered a check and would forward it promptly. Before the checks were issued by Stew-art, on June 21, 2011, Triangle filed this lawsuit against Stewart seeking reimbursement.

Due to the pending litigation Stewart withheld pay-ment until March, 2012 when Stewart paid Triangle the full amount sought, plus interest. Stewart then moved for summary judgment, arguing Triangle’s claim was moot because Stewart paid the full amount demanded. In response, Triangle argued its claim was not moot because it was still entitled to attorneys’ fees under ORS 742.061(1). The trial court agreed with Stewart that Triangle’s claim was moot and granted Stewart’s motion for summary judgment. The court denied Triangle’s fee petition in its entirety. Triangle appealed.

The key issue on appeal was whether Triangle met the “recovery” requirement. ORS 742.061(1) allows a plaintiff to recover attorneys’ fees if three require-ments are met: (1) there is no settlement within six months of the insured’s filing of proof of loss with its insurer; (2) someone brings an action on the pol-icy; and (3) the insured’s “recovery” exceeds the amount of any tender that the insurer made within the six-month period after the insured filed the proof of loss. Triangle argued that it had satisfied the statutory requirements because Stewart had not tendered the full amount of Triangle’s claim within six months of the proof of loss, and Triangle had recovered the full amount of its claim when Stewart paid—i.e., Triangle’s “recovery” exceeded any timely tender by Stewart.

(See Case Study… continued on page 5)

Insurer’s Ability to Avoid Payment of Insured’s Attorney Fees Under ORS 742.061(1) By Jeff Eberhard

Case Study

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OCAA — January 2015 - 5 -

Relying heavily on McGraw v. Gwinner, 282 Or 393 (1978), Stewart argued that a “recovery” for purposes of ORS 742.061(1), is a money judgment, and Triangle did not obtain a money judgment. Rather, Triangle’s claims were dismissed after Stewart voluntarily paid the claim before trial. Tri-angle responded, contending that if “recovery” un-der the statute means only a money judgment, an insurer can defeat the purpose of the statute by waiting until just before the verdict is rendered for the insured to pay the full amount that the insured seeks. Doing so would deprive the insured of the benefit of statutory fees or, alternatively, remove fee exposure as an incentive to pay disputed claims.

The Court of Appeals rejected Triangle’s argument, concluding that “recovery” requires a money judg-ment. Any other means of recovering money from the insurer—even through a jury verdict—does not satisfy the statute. Here, Stewart paid Triangle the full amount of the claim. However, that payment was made voluntarily by Stewart before trial and no money judgment was entered. Therefore, the court concluded, Triangle did not have a “recovery” for purposes of ORS 742.061(1) and it could not re-cover attorneys’ fees from Stewart for the untimely tender.

— View the full case opinion at: http://www.publications.ojd.state.or.us/docs/A152602.pdf

— If you would like to be notified of these new cases, please send an email to: [email protected]. This article is to inform our clients and others about legal matters of current interest. It is not intended as legal advice. Readers should not act upon this information without seeking professional counsel.

Case Study… (Continued from page 3) Medical Notes Lumbar Epidural Steroid Injections By Franklin Wong, MD, Physical Medicine & Rehabilitation Reprinted from INFORM Software Corp Newsletter, December 2014

Find Case Study articles in our past newsletters at: www.oregoncasualtyadjusters.org

Injections of corticosteroids into the epidural space were first recorded in 1952 and have now become a routine treatment option for radicular and low back pain. Since then, over 40 clinical trials evaluating Epidural Steroid Injections (ESI) have been pub-lished, but reported “success rates” have varied from 18% to 90% effective. Many of the studies done prior to 2000 were done without the benefit of fluoroscopic guidance; this procedure flaw probably affected the overall success rate. Since 2000, ESIs are routinely done with fluoroscopy to confirm nee-dle placement.

Mechanism of Action: Low back pain is thought to be related to inflamma-tion following an injury to the disc. Radicular pain

(See Medical Notes… continued on page 7)

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OCAA — January 2015 - 7 -

is thought to be due to a mechanical compression and/or a chemical irritation to the nerve root. Corti-costeroids are used because of their known anti-inflammatory properties.

All approaches are now performed with the aid of fluoroscopy. The performance of ESI without fluo-roscopy is not recommended as studies have shown that misplacement of the needle can range from 26% to 39%, even with an experienced physician.

There are three major point-of-entry options to per-form an ESI:

Interlaminar: The needle is introduced directly into the epidural space. This is a less specific ap-proach in its location and distribution of the ster-oids.

Caudal: The needle is introduced through the sac-rococcygeal ligament located over the sacrum into the epidural space. This, like the interlaminar approach, is a less specific approach.

Medical Notes… (Continued from page 5) Transforaminal: The needle is introduced into the specific nerve root foramen at a specific level, i.e.: Left L4 nerve root. The transforaminal ap-proach is probably now the most commonly used technique because of its specificity and effective-ness.

A variation of the transforaminal injection is a “selective nerve root block,” which is even more specific because it uses a smaller amount of the steroid, and avoids overflow to other nerve roots. With multiple-level pathology, the physician may elect to utilize the interlaminar or caudal approach.

Clinical Perspective: Lumbar radiculopathy: The use of ESI in docu-

mented lumbar radiculopathy is now an accepted community standard although there is still a lack of randomized clinical studies. The role of ESI in the treatment of lumbar radiculopathy with disc protrusion/herniation should not be used in isola-tion, but as part of a comprehensive non-operative treatment plan including an aggressive functional restoration program.

(See Medical Notes… continued on page 9)

Page 8: OCAA News Jan 2015 24 pg - Oregon Casualty Adjusters …oregoncasualtyadjusters.org/articles/OCAA News Jan 2015.pdf · 2015-01-05 · OCAA — January 2015 From the desk of Jeff Eberhard:

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Page 9: OCAA News Jan 2015 24 pg - Oregon Casualty Adjusters …oregoncasualtyadjusters.org/articles/OCAA News Jan 2015.pdf · 2015-01-05 · OCAA — January 2015 From the desk of Jeff Eberhard:

OCAA — January 2015

NEWS from

Around the Web

- 9 -

Spinal stenosis: The use of ESI does appear to provide benefit for patients with a component of claudication (lameness) associated with their spi-nal stenosis.

Axial pain: The growing use of ESI for axial pain without radicular pain is controversial and its role is yet to be clarified. In the theory, the biochemi-cal mechanisms that play a role in radicular pain are responsible for axial pain and thus should re-spond to corticosteroids.

Risk and Complications: In addition to the usual risks and complications of such a procedure, the physician needs to also be aware of the potential of:

Transient substantial hyperglycemia (elevated blood sugar)

It has yet to be determined what is the accepted maximum number of ESIs that a patient can re-ceive in one year, and what is the reasonable time period between injections. If done with fluoros-copy to assure proper needle placement, no fur-ther injections are clinically indicated if there is no positive response following an injection.

Chronic steroid use: The physician does need to monitor the amount of steroid being administered and should also take into account that the patient may also be receiving other corticosteroid injec-tions for their anti-inflammatory properties.

Summary: ESIs do appear to provide short-term effective pain management for documented disc protrusions/herniations with nerve root compression, but they should not be used in isolation, but as a part of a comprehensive non-operative program.

The role of the repetitive use of ESI in spinal steno-sis, axial pain, discogenic pain, and chronic pain syndromes is less clear and controversial.

Medical Notes… (Continued from page 7)

Los Angeles Police Department and National Insurance Crime Bureau Issue Bandit Tow Truck Scam Warning — The Los Angeles Police Department and the National Insurance Crime Bu-reau are warning motorists of a problem with unau-thorized tow truck operators in the LA area.

In a release, the National Insurance Crime Bureau noted it is illegal for a tow truck operator to respond to an accident scene without being requested. (Section 22513 (b) California Vehicle Code).

"These bandit tow truck drivers are breaking the law by responding without being requested," said Lt. Chris Waters, commanding officer of the Com-mission Investigation Division. "They often arrive

(See News… continued on page 11)

To submit an article to this publication contact Barb Tyler at [email protected] or 541/937-2611. Length of the article is not as

important as its content, which should be educational in nature.

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Page 11: OCAA News Jan 2015 24 pg - Oregon Casualty Adjusters …oregoncasualtyadjusters.org/articles/OCAA News Jan 2015.pdf · 2015-01-05 · OCAA — January 2015 From the desk of Jeff Eberhard:

OCAA — January 2015 - 11 -

Magnificent Mention! Thank you to President-Elect Trevor Ar-nold for chairing the 2015 Spring Sympo-sium Committee. They have already had their first meeting with another one sched-uled for January 7. The Symposium will be held on Thursday, April 30, at the Holiday

Inn in Wilsonville. Some interesting topics have been dis-cussed for this year and we’ll follow the same format as last year with the all-day general session and no breakouts.

shows up on the scene, the tow truck driver will re-fuse to unhook the vehicle unless they are given cash to release it.

According to California law: Upon request by the owner of the vehicle, a tow driver must immedi-ately and unconditionally release a vehicle that is not yet removed from private property and in tran-sit. (Section 22658 (B) California Vehicle Code)

LAPD and NICB recommend:

— If you are in a non-injury accident, contact po-lice and your insurance company or motor club to request an authorized tow truck.

— Your insurance company or road side service should provide the name of the tow truck company and expected arrival time. If a tow truck arrives un-expectedly, a call back to the road side service cen-ter should be considered to confirm the tow com-pany is the correct company dispatched.

— Do not be pressured or intimidated into dealing with a tow truck driver that was not requested.

— Do not sign any towing release form that does not clearly spell out the charges involved and the exact location where you want the vehicle taken.

— Use your cell phone to take pictures of any tow truck operator and equipment that shows up on the scene.

— Take pictures of the damage to the vehicles. Some unscrupulous body shops will enhance the damage once they get the vehicle to inflate the re-pair charges.

— If you are injured in the accident, do not be forced into signing a release. Let the police handle the tow.

© 2014 Close-Up Media Inc.

before our officers and pressure the accident victim to sign a release that allows them to take the dam-aged vehicle. Once that form is signed and the vehi-cle is towed, getting it back is expensive."

"Towing charges, which should amount to a few hundred dollars, often skyrocket to a few thousand dollars once the bandit tow truck operator hauls the vehicle away from the accident scene," said NICB Special Agent Doreen Sanchez. "The drivers may say they will take the vehicle to a location of the owner's choice, but they then take it to an undis-closed body shop that is paying them a kickback. In addition to the exorbitant towing charges, the body shop will add on storage fees while the vehicle sits there as the owner and the insurance company are left in the dark as to where it was taken. All of this is designed to maximize the bill to the consumer."

The LAPD and NICB recommend motorists never allow an unknown tow truck operator to tow your vehicle. If you did not request it, reject it.

The LAPD also warns motorists that these bandit tow truck operators also work private parking lots, paying attendants for tips on cars to hook up and haul off to unauthorized locations. If the driver

News… (Continued from page 9)

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OCAA — January 2015

Contact Us  Today: Jenna Gibbs  [email protected]  720.560.6640 www.PTCforensics.com  

proper order: Investigate the coverage first, and ne-gotiate the damages last. The contents of this little black box will keep the adjuster out of trouble.

Until the coverage issues are investigated, evaluated and resolved, one cannot determine liability, be-cause if there is no coverage, liability doesn’t mat-ter. Obviously it is not always that simple. If a cov-erage problem cannot be immediately resolved, it may be necessary to proceed and investigate the type of liability or the nature of the damages under a Reservation of Rights in order to determine if coverage applies. But that is part of the investiga-tion of the coverage.

Waiver and Estoppel The fastest way for an adjuster to get into trouble and end up paying claims not owed is to give the impression that coverage is in order, that there is liability, and the damages will be paid. But when it is determined that there is no coverage or no liabil-ity, the adjuster has made a big “oops!” Coverage defenses are waived and the insurer is estopped from using its defenses. Whether liability for dam-ages is first-party or third-party, coverage is the most important factor.

How many adjusters can recite, word for word, the policy language for every policy under which they handle a claim? Those policies keep changing, and each may come with endorsements or conditions different from the “standard.” There is only one way to be certain that the coverage matches the claim and that is to look at the claim in light of the policy language.

Assuming that we understand the coverage and that it will apply to the loss, we adjusters can get our-selves and our principals into trouble. Joe works at the ABC Company. Joe is injured at work. A simple

(See Adjuster’s Black Box… continued on page 15)

Every profession has some motto and a few secrets hidden in a special place. For physicians, the es-sence of the Hippocratic Oath is “Do no harm.” Their black box is likely a black bag with a stetho-scope and other tools. For attorneys, the motto may be “Litigate the issue!” and the black box is a case for briefs. We adjusters also have a black box, but it’s most often in our head. Our tools are the policy, other contracts, a recorder, a camera, maybe a tape measure, a smart phone and a computer. It is what is in that black box that gives adjusters a basic un-derstanding of what we do: it consists of six words and our motto is: “Never assume!”

Six words can adjust any type of claim: property, casualty, marine or life, and health insurance. In-vestigate, evaluate, and negotiate (or resolve) are the first three words. The next three are: Coverage, liability, and damages. These must be done in the

- 13 -

The Insurance Claims Adjuster’s ‘Black Box’ By Ken Brownlee Reprinted from www.propertycasualty360.com

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OCAA — January 2015

workers’ compensation claim is submitted and paid – and then the adjuster learns that Joe actually works for an independent contractor. Oops!

Mary reports a claim to her auto insurance agent about an intersection accident. Jim’s car was dam-aged and Jim has called the insurer to see where he can have his car repaired. The adjuster tells him where he can have his car repaired and authorizes a rental for the repair time. Then the police report is received and, by golly, it was Jim who was at fault. Oops! These are simple claims, but mistakes are easy.

Too Many Oopses! We’ve all had “oops!” moments. Unless someone constantly monitors our files, we may get away with an occasional “oops,” but if they occur too of-ten, some day that oops will be a disaster and our principal will end up in court trying to explain to a judge or jury what went wrong. The answer lies in that black box; the adjuster forgot to open it and look inside to see what was there. On airliners the black box – although orange or red – reveals mis-takes that pilots may have made that caused a crash.

The adjuster’s black box can do the same – but it can also prevent that crashing “oops!” It’s low-tech, but it works, saving a lot of misery.

Adjuster’s Black Box… (Continued from page 13) professionally and ethically. But what are ethics, and how do they apply to claims management?

The Definition of Ethics I recently reviewed some of the materials of the Ethics 311 and 312 classes offered by The Insti-tutes, and it stated that “Ethics entail knowing what to do when a situation presents more than one ‘right’ answer.” I reviewed several other defini-tions, and the Merriam-Webster definition simply stated that ethics is “the discipline dealing with what is good and bad and with moral duty and obli-gation.”

(See Claims Ethics… continued on page 17)

- 15 -

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Claims Ethics By Gary Jennings Reprinted from www.propertycasualty360.com

Recently, I was in the office of our family orthope-dist and saw the group's mission statement on a poster. As I read the commitments listed there, it occurred to me that all of these could also apply to claims management, but two of them were espe-cially applicable:

We will make our patients our highest priority.

We will conduct ourselves professionally and ethically.

While we would need to replace the word “patients” with “clients” or “policyholders, the theme still holds true. It should also be our commit-ment as claims professionals to conduct ourselves

Page 16: OCAA News Jan 2015 24 pg - Oregon Casualty Adjusters …oregoncasualtyadjusters.org/articles/OCAA News Jan 2015.pdf · 2015-01-05 · OCAA — January 2015 From the desk of Jeff Eberhard:

(541) 937•2611 [email protected]

Barb Tyler

Newsletter Publishing • Executive Assistance • Event Planning Website Development … and more!

Visit us online at: www.alquemiepublishing.com

PO Box 87, Dexter, Oregon 97431 AVAILABLE WHEN YOU NEED US TO BE!

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Providing tailored services to nonprofit organizations since 1994

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Page 17: OCAA News Jan 2015 24 pg - Oregon Casualty Adjusters …oregoncasualtyadjusters.org/articles/OCAA News Jan 2015.pdf · 2015-01-05 · OCAA — January 2015 From the desk of Jeff Eberhard:

OCAA — January 2015 - 17 -

Our clients, whether they are policyholders or self-insured entities that have retained us or our third-party administrators (TPAs) to manage claims, de-serve our efficiency, honesty and professionalism while managing the claims. We must also keep in mind that state laws, case law, administrative proce-dures, and “unfair claims settlement practices acts” as defined by states and by the National Association of Insurance Commissioners (NAIC) also apply. It has always bothered me that laws and standards must be passed to clarify what we must not do, rather than what we should do, but some of the practices describe not only what we should not do, but also remind us of procedures, documents, and communications that should accompany our work to prove without any hesitations that we have prop-erly and fully performed our duties.

How do Ethics Apply to Claims Management? The claims department may be a client's first and only contact with the insurer or third-party adminis-trator (TPA), so the claims organization not only has the responsibility to act ethically and responsi-bly on obvious matters, but must also maintain the appearance of integrity and honesty in all dealings. Policyholders, whether purchasers of commercial lines or personal lines insurance policies, typically have no dealings with anyone in the insurance in-dustry other than the agent or broker until a loss occurs. They do not interact with underwriting or with other departments except perhaps loss control, which may inspect the property or business prem-ises to confirm that the exposure and risk match the information provided on the policy application.

There are often many parties involved in claims management activities, and this sometimes makes decisions more complicated, but we need to ensure that we make our policyholders our highest priority.

For example, a liability claim may involve insurers, policyholders, claimants, reinsurers, attorneys, ap-praisers, and many other professionals. We must ensure that all of these parties perform their duties in the best interest of the policyholder, and that any potential or perceived conflicts of interest are iden-tified and properly managed to achieve an objective outcome. Transparency is a desirable trait and has become an increasingly important characteristic in the business world, and it certainly applies to claims management.

Claims Ethics… (Continued from page 15)

Heather Becker Cell: (503) 575-6161

14200 SE McLoughlin Blvd Suite #G Milwaukie, OR 97267 Office: (503) 594-0545

Toll Free: (866) 993-3817 Fax: (503) 594-0262

[email protected]

We must also recognize that in some cases we must tell clients or policyholders what they do not want to hear, which may lead to unpleasant conversations with those we have given the highest priority. Even in these circumstances we should ensure that our clients and policyholders hear objective expertise from us rather than our acquiescing to the client's every requirement.

For example, some policyholders or clients may insist that we obtain their approval before increas-ing reserves beyond a predetermined value. While clients certainly have the right to be informed of reserve increases based on our professional knowl-edge and expertise, we should resist agreeing to ob-tain their approval. Our clients, or a particular client representative may decide to inappropriately de-press reserve values, which almost always comes back to haunt the client and us at some later point. When that occurs, not only will our client appear to have manipulated reserves, but that same shadow will fall on us as claims professionals.

You can find additional information and examples on this reserving issue in the February 2010 issue of Claims magazine in an article titled “Under Pres-sure: The Temptation to Reduce Reserves Can In-crease in a Poor Economy.”

(See Claims Ethics… continued on page 19)

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OCAA — January 2015

866-737-1331 [email protected]

• PIP and Legal IMEs • Record Reviews • Educational Seminars

Washington & Oregon Experts www.physiciandirectservices.com

“Your Personal IME Service Provider”

As claims professionals, we should always strive to provide the highest level of service. Inherent in this goal is to:

Develop and maintain a high degree of knowl-edge and expertise in areas of concentration.

Rely upon others, such as supervisors, attor-neys, and other specialists, when their exper-tise will augment ours. After all, it impossible for anyone to be an expert in all fields of insur-ance claims.

Have well-documented procedures for the claims programs so that the claims staff is con-sistent and thorough in its work.

Keep clients informed throughout the lives of the claims, which will necessarily require more information-sharing if the claims are more complex or severe.

Protect clients from themselves when it is needed, using your expertise and objective findings to present an accurate assessment to your client.

Resist instructions from clients or policyhold-ers that may lead to inappropriate pressures and direction, or even the appearance of inap-propriate pressure.

These guidelines, along with strict adherence to state requirements and actions to be avoided based on the “Unfair Claims Settlement Practices,” will help claims professionals render service that repre-sents the utmost in strong ethics.

Claims Ethics… (Continued from page 17)

- 19 -

As adjusters we didn’t always think about how many items could be easily restored for a reason-able cost. With our eyes opened to the ease and benefits of restoration, we are amazed at how fre-quently salvageable items are tossed away as trash. When items like furniture, cabinets, millwork, fire-place mantles, and hardwood floors can be repaired and restored, insurers can save money over com-plete replacement and owners are usually thrilled that their treasure has been restored.

Adjusters who know about the expertise available and benefits of repair and restoration over replace-ment can effectively boost their bottom line and have more satisfied clients. The education process includes learning the options… it’s not just furni-ture that can be restored, but dinged walls from moving, spills, puppy chews, scratched leather, chair caning, cabinets and more. If ever in doubt about whether it can be fixed, simply ask.

Customers are typically overjoyed when we can restore a family heirloom because we all know you just can’t put a price on sentimental, one-of-a-kind items. When adjusters call to see if there’s anything we can do to save a treasure from the trash, usually the answer is “yes.”

See next page for a few examples of successful re-pair projects.

(See Restore… continued on page 21)

Adjusters to the Rescue: Trash Can Still Be Treasure, When Properly Restored By Kristi Capps Reprinted from www.propertycasualty360.com

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OCAA — January 2015

OCAA Meeting Minutes of 12/9/14

Meeting called to order by President Tammi McEnaney at 11:50 a.m. Approximately 20 in attendance, including Past President, Margaret DeFrancisco. No Guests.

Treasurer Report by Treasurer Sean McGuire: $10,371.00 and $60 of that is Scholarship fund.

Committee Reports:

— Bowling committee announced that a date/place should be announced at the next luncheon and in the newsletter.

Treasurer Sean McGuire introduced the guest speaker Andy Aberle of Pure Environmental.

Raffle Winners: Wine & Chocolate donated by Pure Environ-mental won by Tammi McEnaney. Lottery tickets donated by Synergy won by Margaret DeFrancisco. Tillamook cheese & meat pack donated by OME won by Margaret DeFrancisco.

There was no winner of the member drawing. Pot goes to $100.00 at the next meeting. Crying Corner: Jennifer Maks – Lenner & Rodrigues, S. Saliman Gray – Mutual of Enumclaw, Brian Driscoll – Barger Law Group, Sarah Hunt – Oregon Mutual, and Shawna Arndorfer - PGE.

Respectfully submitted by President, Tammi McEnaney.

- 21 -

Dining Chair Before After

Harsh chemicals damaged the arm of this dining chair. Expert color matching, wood fill technique, careful repeated sanding, and polishing restored the piece to like new condition.

Many types of contents can be cleaned and restored cost-effectively by knowledgeable professionals, saving claims costs for insurers and precious memories for their clients. When selecting restora-tion professionals, check to see what kinds of certi-fications they hold, what types of training they've had, and whether or not they belong to any profes-sional organizations.

Fireplace Mantle Before After

Smoke and fire damage on the mantle was repaired and it was restored to pre-loss condition using pre-cision repair, wood fill and color matching. Since just one corner incurred damage, money was saved by repair in lieu of complete tear out and replace-ment.

Wooden Cabinet Before After

Water damage to the cabinet top was repaired and the original wood luster restored. Note the wear and tear above the door opening was also repaired. With sanding and polishing, the piece was restored to its original look and feel.

Sofa Table Before After

This family heirloom sofa table was nearly ruined by fire. Not including the sentimental value, this piece would have cost at least $1,000 to replace but was repaired to like new for $500.

Restore… (Continued from page 19)

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OCAA — January 2015 - 23 -

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