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Insurance Claims: A Comprehensive Guide - Product Image

Insurance Claims: A Comprehensive Guide

  • Published: April 2014
  • Region: Global
  • 1500 Pages
  • Specialty Technical Publishers

Insurance Claims: A Comprehensive Guide covers property insurance claims, third-party liability claims, casualty claims, and fraud. It is the most thorough, up-to-date insurance claims guide available. The dos-and-don'ts checklists, sample procedures, sample insurance policy forms, form letters, and tables provide a unique approach.

It is ideal as a practical guide for attorneys (both prosecuting and defense) and business owners who frequently interact with the insurance industry, and as a detailed resource for insurance professionals, educators, and students.

- Authored by an insurance claims and coverage expert witness
- Explains exactly what an insurance claims professional does, offering detailed directions on how to handle claims
- Provides the information necessary to protect the rights of the insured and to obtain the most indemnity to which the insured is entitled
- Discusses the finer points of insurance policies, including different kinds of insurance clauses, conditions, warranties, and exclusions, as well as how and why a policy is declared void, how to process and investigate a claim, how to respond to insurance fraud, and the trial READ MORE >

Volume 1

About the Author


A. History of Insurance

B. Structure of an Insurance Company

C. State Departments of Insurance—Contact Information

D. How to Use this Guide


Chapter I-1 Kinds of Insurance Policies

A. Introduction
1. Property
2. The Contract of Personal Indemnity
3. Liability
4. Differences Between Property and Liability Policies

B. Rules of Contract Interpretation
1. Contract Interpretation and the Reasonable Expectations of the Insured
2. The Reasonable Expectations Test
3. Investigation Required

C. The Property Policy
1. Open and Valued Policies
2. The Declarations Page
3. The Policy Limitations
4. The Perils Insured Against
5. Analysis of the Commercial Property Form
6. Coinsurance or Average
7. Specific of Blanket Coverage
8. Reporting Endorsements
9. The Standard Mortgage Clause
10. Insurable Interest and Brokers

D. The Liability Policy
1. Casualty Insurance
2. Liability Insurance
3. Legal Liability
4. Types of Liability Insurance
5. Liability Policy Format
6. The Commercial General Liability Policy
7. 2002 Changes and Additions
8. The Additional Insured Endorsements
9. Non Cumulation Clauses
10. 2004 Changes



Chapter I-2 Other Insurance Clauses

A. Types of Other Insurance Clauses

1. Pro Rata Clauses
2. Excess Clauses
3. Escape Clauses
4. Contingent Escape Clauses
5. Other “Other Insurance” Clauses

B. Resolution of Conflicts Involving “Other Insurance” Clauses

1. No Other Insurance Clause
2. An Other Insurance Clause In Only One Policy
3. Similar Other Insurances Clauses In Two Primary Policies
4. Dissimilar Other Insurance Clauses In Two Primary Policies
5. Conflicting Other Insurance Clauses In Secondary or Excess Policies
6. Conflicting Other Insurance Clauses In “Specific” Secondary Policies
7. Conflicting Other Insurance Clauses In General or Umbrella/Catastrophe Excess Policies
8. Statutory Involvement

C. Formulae For Apportioning Losses Between Co-Insuring Policies

1. Proration Method
2. Equal Share Method
3. Maximum Loss Method

D. Allocating the Duty to Defend Between Co-Insurers
1. When the Insurers Provide Coverage on a Pro Rata Basis
2. When One Insurer is Primary and the Other Is Excess
3. Duty of Primary Insurer to Excess Insurer

Chapter I-3 Underwriting

A. The Nature of Underwriting
1. Moral Hazard
2. Underwriting Against Moral Hazards
3. Morale Hazard
4. Physical Hazard
5. Unacceptable Risks

Chapter I-4 Conditions, Warranties, and Exclusions

A. Property
1. Conditions
2. Warranties
3. Coinsurance and Deductibles
4. Exclusions

B. Liability
1. Assault and Battery
2. Losses Arising From Possession of Controlled Substances
3. Losses Arising From Professional Services


Chapter I-5 Duties of the Insured and the Insurer

A. Good Faith

B. Property
1. Duties of the Insured
2. Duties of the Adjuster

C. Liability
1. Duties of the Insured
2. Duties of the Adjuster
3. Duty to Defend
4. No Tort Remedy for Non Claims Bad Faith
5. Discovery of Evidence of Claims Bad Faith

D. Duties and Liabilities of Insurance Brokers

Chapter I-6 Declaring a Policy Void

A. When a Policy is Void
1. The Burden of Proof
2. An Arizona Divergence
3. The Majority Rule – Preponderance of the Evidence
4. When “Clear and Convincing” Evidence is Required
5. The Concealment/Fraud Clause
6. Waiver and Estoppel
7. Notice to the Insured

B. Grounds for Declaring Void

C. Returning the Premium


Chapter II-1 Processing a Claim

A. Property
1. Read the Policy
2. Read the Loss Notice
3. Meet With the Insured and Witnesses
4. Establish the Amount of the Loss and Claim
5. Write the Captioned Report
6. Supplemental Reports
7. The Statement of Loss
8. Adjusting the Commercial Loss
9. The Public Adjuster
10. Common Mistakes and Omissions to Avoid

B. Liability
1. The Loss Notice
2. Read the Policy
3. Meet the Parties Involved
4. Visit the Scene
5. Contact Authorities
6. Write the Captioned Report
7. Supplemental Reports
8. Resolve the Claim



Chapter II-2 Investigation

A. Property
1. Determine if Property Damage Occurred
2. Determine if the Policy is Valid
3. Determine if Coverage Exists
4. Determine the Amount of the Loss
5. The Claim File

B. Liability
1. Determine if Coverage Exists
2. The Claim File
3. What the File Should Not Contain
4. Setting Reserves
5. Discoverability of Insurance Claims Files
6. Duty to Defend
7. Single Promise Policies



Volume 2

Chapter II-3 Subrogation and Salvage

A. Subrogation
1. The Tort Remedy
2. The Contract Remedy
3. The Equitable Remedy
4. Cases with Subrogation Potential
5. Retaining a Lawyer

B. Salvage
1. Equitable Salvage
2. Priority of Rights to Salvage
3. Recovery From Third Party Tortfeasors
4. Analogy to Marine Insurance Policies



Chapter II-4 Bad Faith

A. Property
1. Common Law Bad Faith
2. Development of the Tort of Bad Faith
3. Adoption of the Tort of Bad Faith in First Party Cases
4. Arguments Against the Adoption of the Tort of Bad Faith in First Party Cases
5. Courts That Do Not Accept the Tort of Bad Faith
6. Duties of the Insurer
7. Grounds for Finding Bad Faith
8. Avoiding Charges of Bad Faith
9. Punitive Damages
10. Statutory Bad Faith
11. The Duty of the Insured
12. Suspending the Duty of Good Faith
13. Abuses of the Tort of Bad Faith

B. Liability
1. Avoiding Charges of Bad Faith

C. Defenses to the Tort of Bad Faith
1. Genuine Dispute Doctrine
2. The Bad Faith “Set-Up
3. Advice of Counsel
4. Payment of Indemnity Based on Reasonable Evidence



Chapter II-5 The Interview

A. Introduction
1. General Principles
2. Examination Under Oath
3. Obtaining the Truth

B. The Interviewer
1. Remain Objective
2. Establish Rapport
3. Control Emotions
4. Be Confident
5. Maintain Perspective
6. Be a Performer
7. Be Prepared
8. The Importance of Body Language
9. Practice

C. Interviewing a Fraud Suspect
1. Introduction
2. Preparing for the Interview
3. Conducting the Interview
4. The Length of the Interview
5. Evaluating the Interview

D. Interview Techniques and Approaches
1. Introduction
2. Questioning Techniques
3. Interview Approaches
4. What to Avoid in an Interview
5. Conclusion

E. The Psychology of Interviewing
1. The Danger of Relying on Memory



Chapter II-6 Preparing a Case for Trial

A. Counsel
1. Retaining a Lawyer
2. Relationship With the Defence Lawyer
3. Reporting Requirements
4. Involvement of the Adjuster

B. Early Investigation
1. Initial Evaluation
2. Litigation Plan
3. General Discovery
4. The Claim File
5. Trial Preparation
6. Conflicts of Interest

C. The Right to Independent Counsel
1. The Cumis Doctrine
2. Reservation of Rights
3. Restraint on Independent Counsel
4. Adjustment of a Potential Cumis Case


Chapter II-7 Evaluation and Settlement

A. Property
1. Structure Losses
2. Contents Losses
3. The Proof of Loss

B. Liability
1. Damages
2. Liability
3. Considerations for Early Settlement
4. Settlement Negotiations
5. When a Claim Should Not Be Settled
6. Dispute or Denial of a Claim
7. Model Regulations of the NAIC to Enforce the Fair Claims Practices Act




Chapter III-1 Identifying Insurance Fraud

A. Introduction

B. Types of Insurance Fraud
1. Soft Fraud
2. Hard Fraud
3. Professional Conspiracies
4. The False Claims Act and the Qui Tam Suit
5. Fraud in Low Speed Rear End Accidents
6. Insurer Fraud
7. Broker Fraud
8. How to Join the Fraud Fight
9. Summary

C. Investigating Fraud
1. Training the Investigators
2. Red Flags of Fraud
3. Investigation Methods
4. Case Studies of Successful Fraud Investigations
5. Specialized Investigations



Chapter III-2 Responses to Fraud

A. Denying a Claim
1. Grounds for Denying a Claim
2. Grounds for Rescission
3. The Denial Letter
4. Settlements
5. Taking a Fraud Case to Trial

B. The Fight Against Fraud
1. Battling Public Opinion
2. Insurance Industry Weapons
3. The Legislative Arsenal
4. One State's Fight Against Fraud
5. The Role of Victims in Criminal Investigation and Prosecutions
6. Is the Fight Against Fraud Being Lost?
7. Summary



arry Zalma is an insurance coverage attorney, consultant and expert witness. As a California attorney, Mr. Zalma limits his practice to transactional, rather than litigation, counsel concerning insurance coverage matters, mainly representing insurers and those in the business of insurance. Mr. Zalma was licensed to practice law in 1972 and has operated his own firm since 1979. He is admitted to practice before all California courts, California U.S. District Courts and the Ninth Circuit Court of Appeals. His full curriculum vitae is available on his web site.

Through Zalma Insurance Consultants Mr. Zalma consults with insurers, insurance brokers and agents, and policyholders internationally. He assists counsel for insurers and policyholders on insurance coverage issues, claims handling, and bad faith claims. Mr. Zalma has represented insurers from Allstate to Underwriters at Lloyd's, London and from Westfield Insurance Company to Allianz Insurance Company. Mr. Zalma has qualified as an expert in state and federal courts in California, Mississippi, Texas, New Mexico, Oklahoma and the British Crown Colony in the Grand Caymans.

Mr. Zalma has authored several books and e-books on property and liability claims, numerous articles for insurance trade publications and law journals, a twice monthly publication, Zalma's Insurance Fraud Letter, a daily blog Zalma on Insurance and regular columns in American Agent and Broker magazine and the Underwriters Insider. He acts as an expert commentator for the International Risk Management Institute; is a member of the faculty of the Insurance Agents and Brokers of America's Virtual University; and is the author of distance learning and computer-based training programs for people in the business of insurance.

Mr. Zalma is a member of the American Bar Association, the Southern California Defense Counsel, the Defense Research Institute, the Southern California Fraud Investigators Association (SCFIA), the California Conference of Arson Investigators, the International Association of Arson Investigators, the Forensic Expert Witness Association (FEWA), and the Association of Certified Fraud Examiners.

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