home about us services MMSEA technology Contact Us login links sitemap support Image Map
Claim File Expectations
CORPORATE CLAIMS MANAGEMENT, Inc. .

 CLAIM FILE EXPECTATIONS  

Corporate Claims Management, Inc. was founded on the premise that the risk management community was in need of a high-quality, sophisticated third party administrator that could custom tailor the delivery of its product to meet the specific needs of the client. Utilizing a well-trained staff and state-of-the-art risk management information systems, CCMI will provide the highest level of service available to investigate, evaluate, and understand losses that are experienced. Paramount to filling this role is the delivery of a well-handled claim file. In order to deliver a product that meets our clients' needs, these Claim File Expectations have been developed that define how Corporate Claims Management expects its staff to manage the claims that are assigned.

Although it is important to recognize that each client's needs may be different, Claim File Expectations are to be used as our guiding principles, and may only be deviated from with written instructions from our client.

1. Initial Assignment/Activity

2. Coverage Verification

3. Initial Investigation

4. Reserving Practices

5. Medical Management and Disability Control

6. Litigation Management

7. Claim File Management and Supervision

8. Claims Information Data

9. Claim Disposition Philosophy

Top


1-Initial Assignment/Activity

Claim assignments will be accepted by the method most convenient to the client. Assignments may be made by telephone, FAX, courier, mail, or other means as necessary. All claim assignments received by FAX, courier, or mail shall immediately be date-stamped and given to the Account Manager or Claims Adjuster assigned to the account. Telephone calls to report claim assignments shall immediately be referred to the handling Account Manager or Claims Adjuster for immediate contact and investigation.

Top



 
2-Coverage Verification

All files must reflect proper documentation that coverage has been reviewed and is in order. Where coverage appears questionable, policy and jurisdiction issues must be explained. Employer/employee relationships must be identified and alternative policy availability must be researched. If a subsidiary company is involved in a loss, identify the company and their relationship with the named insured/client. Documentation must include identification of the carrier, policy number and term, applicable deductibles, SIR, limits, and endorsements.

All coverage issues must be referred to the appropriate Claims Manager immediately. For insured accounts, all coverage issues must be referred to the appropriate insurance company office, with a copy of the referral letter to the insured and broker. For self-insured accounts, all coverage issues must be referred to the insured, with a copy to the broker and excess carrier. For group self-insured accounts, all coverage issues must be referred to the group self-insurer's Administrator, with a copy to the broker and excess carrier, if applicable.

Top

 

 3-Contacts Investigation

Claim assignments that are received via telephone call will be immediately referred to the appropriate Account Manager or Claims Adjuster for initial handling. For claim assignments (other than Workers' Compensation Medical Only) received via any other method, concrete activity - including aggressive steps to contact all parties to the loss and the start of the initial investigation - must be documented in the claim file within 24 hours of the receipt of the assignment. Acceptable contact may be made by telephone or in person, as determined by the allegations of the loss and/or seriousness of the claim. Field investigation assignments shall be immediate, unless the file documents why no field investigation was initiated.

For Workers' Compensation (other than medical only) losses, acceptable contact/investigation will include productive contact with the injured worker, employer and medical providers, or multiple attempts at contact through various means. The use of form letters shall only be considered acceptable if attempts to contact the injured worker are documented within the first 24 hour period, or the file clearly reflects why contact with the injured worker is not possible (an acceptable example of this is where attorney involvement precludes our ability to contact the worker). The use of form letters shall never be considered an acceptable form of contact with the employer or medical provider. Claim files shall document (in the progress notes) a complete and detailed record of the results of this initial contact, as well as all future telephone or in-person conversations. Claim files shall document the discussion of applicable benefits owed, as well as the action plan developed to bring the case to a speedy conclusion. All cases involving compensable lost time or the possibility of permanent partial disability shall contain a recorded or written statement of the injured worker. Files that may be disputed or controverted shall also contain recorded or written statements of other parties having knowledge of the loss as may be appropriate. In lieu of the completion of this requirement, files may be considered acceptable if there is clear and complete documentation as to why the statements were not obtained (for reasons such as that the party was incapacitated, or the refusal by the party to allow the statement). All files containing a recorded statement shall also contain complete documentation (either in the file notes or on a separate sheet kept with the statement tape) relative to the contents of the recorded interview.

Initial investigation/documentation shall also contain comment relative to acceptance of or questions of compensability that need to be determined through continued investigation, the possibility of and steps necessary to proceed with the pursuit of subrogation against responsible third parties, coverage issues (including concurrent coverage, or facts that might lead to a question of coverage) and an action plan detailing what further steps need to be accomplished in order to bring the claim to conclusion. All file documentation in these areas, as well as all other file documentation, must be complete enough to allow the reader of the file notes to have a clear understanding of the issues, actions, and action plans contained in the file. All file notes should contain a final comment detailing the plan of action to bring the claim to conclusion, the next steps to be taken to bring the file closer to conclusion, a date that each of these items is expected to be concluded, and a diary date for the claim handler's next scheduled review. Unless the file clearly documents reasons for a longer diary, all files will be kept on a maximum diary period of 30 days.

For Liability losses, acceptable initial contact/investigation shall first include comment relative to coverage issues. Early recognition of coverage issues and timely and proper submission of coverage questions to appropriate resources shall be conducted concurrent with other investigation items, and non-waiver/reservation of rights notifications shall be issued in accordance with instructions from the client. Acceptable initial contact/investigation shall include productive contact with the client and claimant or their representative, as well as the establishment of good rapport with the claimant to avoid unnecessary legal actions, including first call settlement attempts, where possible. The use of form letters shall only be considered acceptable if attempts to contact the claimant are documented within the first 24 hour period after receipt of the assignment, or the file clearly reflects why contact with the claimant is not possible. The use of form letters shall never be considered an acceptable form of contact with the client. Claim files shall document (in the progress notes) a complete and detailed record of the results of this initial contact, as well as all future telephone or in-person conversations. Claim files shall document the discussion of an action plan developed between the client, claimant, and claims handler to bring the case to conclusion. All cases involving a known or suspected Bodily Injury shall contain a detailed, recorded or hand written statement of the injured claimant, as well as other parties and witnesses to the loss. Regardless of injury, cases (other than windshield cases) that will likely result in the denial of liability on behalf of the client shall also contain recorded or written statements of the parties to the loss as may be appropriate. In lieu of the completion of this requirement, files may be considered acceptable if there is clear and complete documentation as to why the statements were not obtained (for reasons such as that the party was incapacitated, the refusal by the party to allow the statement, or that it was in the claim handler's best judgment to not record a statement in an effort to control the claimant). All files containing a recorded statement shall also contain complete documentation (either in the file notes or on a separate sheet kept with the statement tape) relative to the contents of the recorded interview.

Initial investigation/documentation shall also contain comment relative to acceptance or questions of liability that need to be determined through continued investigation, as well as items necessary to determine the damages owed. Medical Authorizations should be sent, Police Reports and other official reports ordered, and appraisals assigned when appropriate upon the initial handling of the loss. Files shall contain documentation relative to the need for experts in determining liability or damages, and approval to employ the same from the client.

Central Index System

All bodily injury claims and workers' compensation claims (except workers' compensation medical only claims) shall be submitted to the Central Index System within seven days of the receipt of such claim via automated claim reporting procedures. Positive results of all index inquiries shall be investigated immediately and thoroughly, with the results of such investigation documented in the claim file.

All claim files meeting Central Index System reporting criteria shall be re-indexed every six months until such claim file is closed.

Top

4-Reserves

The establishment and maintenance of an appropriate loss reserve level is critical to the success of all of our clients' programs. Changes in loss reserves, based on the continuing investigation and evaluation by the claims personnel must be reflected immediately. It is Corporate Claims Management's goal to stabilize all reserves to the probable ultimate cost of the claim within twelve months from our receipt of the loss notice.

Initial reserves, to reflect the probable ultimate cost of the loss, shall be entered into our Corporate Systems data base within forty-eight (48) hours of our receipt of a claim, and is to be based on the information known at the time, discovered through the initial investigation process.

For workers' compensation (other than medical only), all initial and subsequent reserves shall be based on calculations made on a reserve work sheet, detailing the various components of the medical, indemnity, and expense portions of the reserve. Either a manually completed or automated (CS) reserve work sheet will be considered appropriate. Manual reserve worksheets, if used, shall be signed and dated, and shall be kept on the left-hand side of the file jacket. Formula, bulk, and stair step reserving must be avoided. Elements of the Reserve Work Sheet must provide the specific breakdown:

Indemnity Reserve - Temporary Total Disability, Temporary Partial Disability, Permanent Partial Disability, vocational expenses, Permanent Total Disability, Death Benefits, dependency benefits, etc.

Medical Reserve - attending physicians, specialists, diagnostic testing, medication,
rehabilitation, attendant care, transportation expenses, hospitalization expense, etc.

Allocated Expense Reserve - attorney fees, court costs, surveillance expenses, expert fees, medical cost containment fees, etc.

All reserve changes should be posted within 24 hours of fact development that clearly warrant the change. Reserves on fatal, permanent total disability, or other life time indemnity benefit cases are to be established based on tables mandated by the Workers' Compensation Act. Adequacy of reserves must be determined each time the file is reviewed and documented in the file.

For liability claims, all initial and subsequent reserves shall be based on calculations made on a reserve work sheet, detailing the various components of indemnity and expense portions of the reserve. Either a manually completed or automated (CS) reserve work sheet will be considered appropriate. Manual reserve worksheets, if used, shall be signed and dated, and shall be kept on the left-hand side of the file jacket. Formula, bulk, and stair stepping reserving must be avoided. Elements of the Reserve Work Sheet shall contain the following elements:

Indemnity Reserve - separate reserves for bodily injury and property damage. The worksheet must reflect the type of injury sustained or property damaged, funeral expenses, estimated medical expense, estimated wage loss, any permanency, general damages, etc.

Allocated Expense Reserve - Attorney fees, court costs, surveillance expense, expert fees, etc.

All reserve changes should be posted within 24 hours of fact development clearly warranting the change. Adequacy of reserves must be determined each time the file is reviewed and documented in the file.

Top



5-Medical Management and Disability Control

For Workers' Compensation losses, proper medical treatment must be provided timely and in a cost efficient manner. Claim files must document immediate initial contact with medical providers, outlining the provider's opinion on causation, the diagnosis, prognosis, treatment plan, as well as the expected length of medical treatment. During the employee's period of disability, subsequent medical visits must be documented in the claim file within 24 hours of the subsequent medical treatment. Disability must be medically documented and contained in the claim file prior to the issuance of any disability payments. Documentation can be in the form of reports from attending physicians or Claim Progress Notes documenting that the medical provider was contacted and that the disability is medically authorized, and/or that the employer cannot accommodate a light-duty release with the restrictions prescribed. Recovery target dates or subsequent medical treatment dates must be established and clearly documented in the claim file. IME's and second opinions must be obtained when appropriate. Causal relationship of the present treatment to the industrial injury must be delineated.

Proactive disability control to end/minimize lost time and disability consistent with sound medical evidence must be documented. Active exploration of early return to work programs, modified work, or part-time employment must be pursued. Job descriptions should be provided to the attending physician to facilitate the earliest return to work date.

Cases with continuing disability of four weeks or more with no return to work date established should be reviewed for possible assignment to a medical/vocational rehabilitation specialist. Claims with obvious long-term disability components or extended medical treatment should be referred immediately to a medical rehabilitation specialist for review.

Every effort must be made to utilize rehabilitation, case management techniques, PPO networks, provider bill audits and utilization review services to control overall indemnity and medical expense. Any provider bill in excess of $10,000 must be submitted for audit pre-screening by a qualified managed care provider prior to payment. Pre-screening findings and recommendations should be forwarded to the account for a decision relative to performing an actual audit of the bill. Prescreening results should document the areas of concern with the bill, the expected cost of the audit, and a statement as to the potential savings that might be realized. Assignment or referral for case management to a third party provider must only be made with the consent of the client. Upon assignment or referral, goals must be established and budgets agreed upon. File management remains the responsibility of Corporate Claims Management. In no instance is the file or any component of the file to be abandoned to the medical case management firm.

All catastrophic losses are to be reported to a qualified medical management specialist within 24 hours or receipt of the first report for initial assessment and review.

Top

 

 

6-Litigation Management

It is Corporate Claims Management's philosophy that Litigation Management begins from the moment an assignment is received from our client. The most beneficial way to manage the client's litigation exposures, and thereby reduce the client's litigation expense, is to conduct a timely, complete investigation and to evaluate the case fairly, based on its merits. Early claimant contact, effective claimant control, and continued claimant communications throughout the life of the file - all very basic claims handling methods - will benefit the client's litigation experience through a reduction in the amount of lawsuits filed.

Despite our best efforts, however, litigation is and will continue to be a part of the claims adjusting process. Differences of opinions relative to coverage, liability, compensability, and damages are sometimes not negotiable. As well, plaintiff oriented attorney practices foster pro-litigation attitudes that are, sometimes, not circumventive. As a result of these unavoidable factors, and as a result of the escalating costs associated with litigation, Corporate Claims Management has developed the following procedures to serve as a guideline for managing the litigation process on behalf of our clients.

It is incumbent upon Corporate Claims Management to provide the finest quality defense in an efficient and cost effective manner for our clients. We fully recognize that the client must have input in the selection of defense counsel, and commit that the client will be allowed to choose appropriate counsel on each assignment. Likewise, we fully recognize that, because of the nature of some of the claims we're assigned, the most efficient and cost effective defense may require the assignment to defense counsel in anticipation of litigation to preserve the attorney/client privilege, and to protect the information that might be discovered during the course of our investigation. While, under these circumstances, we will be instructed and guided by counsel, in no case, however, will Corporate Claims Management abandon the responsibilities entrusted to us by the client to defense counsel.

Effective and economically sound litigation management is achieved by close teamwork between the CCMI Account Manager, defense counsel and our client. Our objective is best achieved by establishing a sound, long-term relationship with defense counsel. Through this "partnership" relationship, we and defense counsel can best understand and be most responsive to the needs of our clients.

Case Referral/Assignment
Upon receipt of a lawsuit, or when assignment to counsel is contemplated in anticipation of litigation, the Account Manager must consult with the client (or refer to the client's approved counsel list, if appropriate) for concurrence on attorney selection before the assignment is made, and to discuss any coverage issues that might be involved. Recommendations of attorneys to the client must be based on the attorney's ability and experience with the type of loss that is the subject of the litigation (as an example, for truck liability losses, the recommendation should be consistent with the Trucking Industry Defense Association (TIDA) approved counsel directory). It is imperative that the assignment be made to a specific attorney within the firm, and must be made - via telephone, initially with follow-up confirmation via FAX - on the same day that the lawsuit arrives. FAX confirmation is to become a part of the claim file. The assignment must provide clear instructions relative to the direction and reporting requirements of the client, and is to be followed by an assignment letter (with a copy of the file attached) that details the handling requirements for the loss.

If coverage is at issue, the sending of a Reservation of Rights to the defendant or insured may be in order, and should be issued immediately, with the concurrence, and within the claim handling guidelines/requirements of the client.

An Extension to file the Answer to the lawsuit should be requested from Plaintiff Counsel on each lawsuit. Any Extension granted must be promptly acknowledged to Plaintiff Counsel in writing, with copy to the client/defendants.

Defense Counsel Acknowledgment

Within five working days, the attorney will acknowledge receipt of the assignment, which will include an initial review and opinion of the matter as well as a date-oriented suggested action plan and expected budget for activities during the first 60 days. If there are additional activities which Counsel believes are necessary to the defense of the case that have not been specifically set forth in the initial instructions, Counsel shall immediately notify the Account Manager. A preferred initial status report form is attached hereto.

Case Development

The development of a focused and strategically sound legal defense is the joint responsibility of counsel and the Account Manager, with ultimate concurrence by the client. Upon receipt of Defense Counsel's acknowledgment, all parties should develop an action plan and corresponding budget relative to the defense of the lawsuit. Elements of the action plan should include but not be limited to the following:

  1. Identifying and developing all appropriate liability issues
  2. Bringing viable third-party actions and/or cross complaints against co-defendants
  3. Developing the defense of contributory or comparative negligence
  4. Raising causation issues relative to the damages claimed
  5. Analyzing critically the basis of all damage claims  
  6. Exploring the viability of Alternative Dispute Resolution (ADR)



Direction of the overall claim investigation is the responsibility of CCMI. Investigation shall be conducted by claims personnel with guidance from counsel where appropriate. Counsel shall not conduct investigation without specific instruction from or approval by CCMI or the client. All requests for investigation must be addressed to CCMI. The Account Manager will then secure the investigation information, utilizing field investigators as needed, or authorizing formal discovery where appropriate. Expert witnesses, including medical witnesses shall not be engaged without prior CCMI approval, with concurrence by the client. Independent medical examinations will be scheduled by CCMI. Any exception to items in this paragraph must be approved in advance by the client.

CCMI shall evaluate the use of motions and depositions, directing their effort toward having a positive and value added impact on the case. Motions or depositions that do not advance the case or provide a realistic strategic value will not be authorized. Further, all Motions for Summary Judgment, Demurrer, In Limine, etc., discovery motions, and third party actions must have pre-approval by CCMI, with concurrence of the client.

The propounding of Interrogatories to the Plaintiff must have approval of CCMI and the client, and must be forwarded to CCMI prior to being served on the Plaintiff. Likewise, Plaintiff's Interrogatories directed to the client should be completed by the client, with assistance as required by CCMI.

 

Suit Disposition

CCMI recognizes that the pre-trial and trial phases of litigation are the most costly portions of the client's litigation program. For these reasons, CCMI's heightened involvement in these stages of the process is mandatory. Responsibilities of the various parties must be clearly defined and communicated regularly during this period. A Pre-Trial Analysis Report is due 60 days prior to trial or mandatory arbitration, even if all discovery is not complete, in the format attached hereto.

When a settlement conference, mediation, arbitration or other form of ADR is scheduled, counsel shall confer with CCMI to determine whether the attendance of a client representative is desirable or mandatory. CCMI can attend settlement conferences on the client's behalf, with approval. If it is decided that no representative need attend, then arrangements for telephone contact with CCMI during the proceeding must be established. Counsel must inform CCMI of the date and time that telephone availability is required.

CCMI must instruct counsel that requests for settlement authority must be made on a timely basis, and in line with counsel's previously stated evaluation of the case. Requests for authority at the time of trial or the day before a settlement conference will not be tolerated. Requests for settlement checks must be in writing. Counsel should be aware that large dollar settlements may take time to process in order to permit the necessary control and security procedures to be applied. Counsel may not make any promises concerning the delivery of settlement checks without prior approval of CCMI.

CCMI mandates that any case that proceeds to trial requires oral report by counsel to CCMI at least twice each day. The decision to accept a jury verdict can only be made by the client, taking counsel's recommendation into consideration.

 

Reporting Requirements  

CCMI mandates that within 60 days of assignment, counsel must submit an initial status report, as attached, for both Casualty and Workers' Compensation cases. The time for submitting the initial status report and the format of the report may be altered upon agreement of the client.

CCMI will instruct Counsel that all significant events, such as depositions and court appearances, must be reported immediately. Whenever events change any fact, judgment or opinion on the case, a revised Attorney Status Report (and corresponding budget) must be submitted as soon as practicable. Reports should not repeat previously reported events. Counsel must report on all files at least every six months, even if there has been no activity.

CCMI will instruct Counsel that depositions and other discovery should be briefly summarized and a written report submitted within 14 days of the deposition or receipt of discovery. The report should include counsel's impression of the witness, the effect upon the case, the effect upon the defense strategy, and any recommended future activity resulting from the receipt of discovery.

Counsel will be instructed to notify CCMI of any settlement conference or trial date as soon as the date is set, even though these dates are frequently postponed. If a date is postponed, counsel must notify CCMI of the new date as soon as it is established.

Counsel will be instructed to provide the following types of documentation as they develop:

1. Defense's answer to the lawsuit

2. Any amended complaints

3. Any third party pleadings

4. Copies of pleadings and motions filed

5. Correspondences and reports

6. Releases, dismissals, or judgments


Budgets
 

Together with the Assignment Acknowledgment Form, counsel will be instructed to submit an initial Litigation Budget. This budget will include all activity anticipated for the first six months of the litigation, implementing the litigation instructions and other agreed activities to achieve meaningful file development, and focused legal activity within that period. Any changes to this budget should be discussed with CCMI immediately. Counsel will be instructed to prepare additional budgets for the entire life of the file, at six month intervals. Whenever any fact, opinion or evaluation changes, a new budget may be prepared, reflecting the changed circumstances.

Approved Billing Practices

CCMI must be advised of billing rates prior to retention of counsel. Increases in any billing rate must be provided in writing prior to the effective date of the increase. Counsel will be instructed to submit invoices on a regular, quarterly basis from the date of assignment. Counsel will be advised that no flat charges as a part of its rate structure will be considered, unless such charges have been agreed to in advance. All billing will be in increments of 1/10 of an hour.

Only reasonable travel and other expenses that have been incurred with CCMI or client prior approval will be reimbursed. Only coach class airfare, moderately priced hotel accommodations and moderately priced meals will be reimbursed. Travel expenses shall be itemized on counsel's billing, with copies of all receipts attached.

We will recommend that our clients deny reimbursement to counsel for intra-office conferences, file memoranda, memoranda to staff, or any other form of intra-office conference, whether oral or written. Likewise, we will not recommend payment of fees for repetitive file reviews caused by the use of multiple attorneys assigned to a case. Unless otherwise approved in advance, only one attorney is authorized to attend depositions, meetings, court appearances, etc.

Counsel will be instructed that any extensive research project must be discussed with CCMI in advance. Since assignments are made to firms which have been selected for their expertise in particular areas of law, we will not recommend payment for research that is routine in nature. It is anticipated that routine discovery motions, if approved, will not require any special research.

 
CCMI will not consider payment of any of the following items  

  1. Word Processing, clerical or secretarial charges
  2. Storage of open or closed files, rent, electricity, local telephone, receipt of telecopier documents, or other items traditionally associated with overhead.
  3. Telephone, telecopier, postage, courier, or any other service in excess of the amount actually expended by the firm for such service.
  4. Auto mileage rates in excess of the rate approved by the Internal Revenue Service for income tax purposes.
  5. Equipment, books, periodicals, research materials or other like items.

 

CLAIM RECOVERY

Incumbent to our role as claims adjusters and administrators on behalf of our clients is the evaluation of each claim assignment for the possibility of contribution or recovery from responsible third parties and other methods of loss mitigation, such as the sale of salvage, offsets against second injury funds, social security benefits, or other such offsets. While workers' compensation benefits owed to the injured employee are regulated by state statute, and while indemnity payments on behalf of our clients might be warranted because of the facts of a liability case, we mustalways look for ways to reduce our client's losses by recognizing and pursuing contribution from joint-tortfeasors or responsible third parties to the loss. Although we are not an insurance company that is "subrogated to the rights of our insured", sound claims judgment should be utilized to the benefit of our client in this regard, as with all aspects of our contractual responsibilities.

Each claim assignment should be evaluated for the existence of third party recovery or contribution, and should be documented accordingly in the claims progress notes. For self-insured accounts, third party recovery or contribution possibilities should immediately be referred to the client for recommendation and advice, as certain business relationships or contractual obligations outside of the subject claim may prohibit the active solicitation of contribution or recovery efforts in certain instances.

In every case, however, recovery potential must be recognized, investigated and pursued in a timely fashion. The claim file should reflect a strategic approach in developing and pursuing recovery, including on-site investigations and use of experts in evaluating loss. Aggressive pursuit resulting in claims recoveries will mitigate the client's ultimate loss figure. If recovery potential is not applicable, the file will be documented with an explanation.

All proceeds from recoveries must be made payable to our client, unless specifically instructed in writing by the client to the contrary.

  Top  

7-Claim File Management

Inherent to all high-quality claim products is the existence of a clearly defined claim resolution strategy that outlines the expected course of the claim file through closure. The utilization of stated goals and objectives, including established time frames for the completion of tasks essential to the proper handling of the file, is a requirement of all claim files entrusted to Corporate Claims Management by our clientele. Documentation of the claim resolution strategy, including an outline of work to be completed, must be contained in the Claim Progress Notes in the file, and is to be updated upon review or as the facts warrant.

The utilization of an effective claim diary is a fundamental element to proper claims administration. Adjusting personnel are required to maintain a diary system on each claim file. The stated diary date should be consistent with the time frames necessary to properly manage the claim, and should reflect sound claims judgment that is consistent with the claim resolution strategy. All claim files must be kept on a diary to allow for review every 30 days or less, unless the file clearly documents why a longer diary period is warranted.

CLAIM SUPERVISION

Corporate Claims Management exercises great effort toward hiring only the most qualified personnel to deliver claims administration services to our valued accounts. We believe that we must remain dedicated to the mission of employing only those claims professionals possessing a strong sense of customer service and unwavering pride in their work if we are to continue to deliver a superior product.

It is Corporate Claims Management's belief, however, that all personnel require supervision. The nature and depth of supervision afforded to an employee will be based upon that individual's specific needs, degree of expertise, and proven ability in delivering a superior product. Regardless of these factors, each open claim file must be reviewed by a supervisory or managerial level employee every 60 days or less. Claim supervisory reviews are to include an analysis of the adequacy of reserves, analysis of general file direction, and claims handling/follow-up instructions as warranted. Claim supervisory reviews should be documented in the claim progress notes of the file, with a required completion date for all claims handling/follow-up instructions given.

Top

8-Claims Information Data  

As essential as any other facet of our claims adjusting process is the necessity for accuracy and integrity of claims data that we track for the losses received. The information tracked by Corporate Claims Management is essential to the management of our clients' businesses. It is incumbent upon us to make every effort to provide our clients with accurate data that will allow for reliable reports and analysis of the losses referred to Corporate Claims Management, Inc.

Corporate Claims Management has committed to each client that it will provide unparalleled risk management information systems as a tool by which our clients can develop loss information to meet their specific needs. We must remain dedicated to the collection of accurate and useful data in line with these needs if we are to remain an integral part of the client's overall risk management program. Basic to that commitment is the development of detailed Corporate Systems Account Design that is custom-tailored to meet those client-specific needs. In all instances, the Corporate Systems Account Design will be developed in concert with the instructions and risk information needs of the client. Claim Number sequences, Location Code structures, Cause of Loss codes, and any Special Analysis format will be detailed in the Account Design to allow for an end-user friendly data base encompassing the needs of the client. Corporate Claims Management personnel must constantly look for ways to fine tune the data collection elements to meet the ever-changing needs of each of our clients.

Each Claims Assistant, Claims Adjuster, Account Manager, Claims Supervisor and Claims Manager have the responsibility to insure that the data entered into the Corporate Systems Data Base is one hundred percent accurate. This responsibility not only includes the person that initially enters the data, but extends to each person that handles or reviews the claim file throughout the adjusting process. Any data error detected must be corrected immediately. Claims Supervisors and Managers must be aware of trends in carelessness and inaccuracy, and are responsible for counseling the employee on the need for error-free risk information data. Non-compliance in meeting Corporate Claims Management's objective of one hundred percent data accuracy will be considered equal to failing to meet any other claim related objective of these Expectations. Continued non-compliance in meeting these objectives will impact the employee's performance evaluation in the same fashion as non-compliance in any other facet of the employee's responsibility.

Loss payment codes, which are entered into the system each time a payment is requested, must also be one hundred percent accurate. Inaccurate payment coding will be tracked by the Claims Manager and/or Claims Supervisor, and will become a part of the employees performance evaluation.

The Corporate Systems claims administration system has sufficient safeguards to prevent duplicate payments of claims. ANY INSTANCE OF DUPLICATE CLAIMS PAYMENTS MUST BE ADDRESSED IMMEDIATELY BY THE CLAIMS MANAGER AND/OR CLAIMS SUPERVISOR, WITH APPROPRIATE CORRECTIVE ACTION TAKEN.

As important as accuracy in data collection is timeliness. Client decisions that are contingent upon the data that Corporate Claims Management collects must be made on information that is both accurate and timely. Data from new claims assignments must be entered into the claims administration system within forty-eight (48) hours of our receipt of the loss notification. Information received that changes the financial implications of the loss or any other facet of the claim must be entered within twenty-four (24) hours of our receipt of such notification or information. Timeliness of data collection will be tracked by the Claims Manager and/or Claims Supervisor, and will become a part of the employee's performance evaluation.

Top


9-Claim Disposition

The proper disposition of claims assignments is, ultimately, what our clients have contracted our services for. Timely, cost-efficient, good-faith resolution of claims presented against our clients, in line with any special claim handling guidelines governing these activities, must be our top priority.

All claim files must contain a resolution strategy and action plan to bring the file to a timely and cost effective resolution, within settlement value ranges that are appropriate for the elements particular to the subject claim.

Claim files must clearly indicate the basis of any proposed claim settlement, and must contain sufficient claim related documentation to support such proposed settlement. For all lines of coverage which result in a bodily injury claim or work related injury claim, this must include medical reports or other documentation from attending physicians and other medical providers which detail the type of injury sustained by the claimant, including a descriptive analysis of the medical condition, the causal relationship to the alleged incident giving rise to the claim against our client, the prognosis, and amount of permanent partial disability resulting from the injury sustained from the alleged incident, if any. Ratings of permanent partial impairment must clearly define any pre-existing condition, and the effect of that condition on the subject claim. Claims for loss of earnings (past or future) must include sufficient, reliable documentation to support this portion of the claim before any due consideration may be given. Payment of any claim settlement for any bodily injury type of claim must be exchanged for a full and final release of all claims, naming the client and any employee of the client (or other related co-defendants, as applicable) as the released party. Partial settlements or advances on final settlements can only be issued with the express written instructions of the client. Payments for compromise lump sum settlements of state workers' compensation claims must be offered in good faith in line with the rules and regulations of the state of jurisdiction.

Claims for property damage arising from the alleged incident must be clearly documented in the form of written damage appraisals or repair estimates. Corporate Claims Management personnel are encouraged to utilize independent damage appraisers familiar with the type of property damaged to analyze the amount of damages attributable to the alleged incident. Property damage losses resulting in claims for less than $1,000.00 may be settled on the basis of a written repair estimate, so long as the claimant has supplied at least two independent, itemized repair estimates detailing the scope of repairs contained in the estimate. Open items must be clearly defined and contained in the written repair estimates, and duly noted in the claim file. PRIOR TO RECOMMENDING SETTLEMENT OF ANY PROPERTY DAMAGE CLAIM ON THE BASIS OF COMPETITIVE REPAIR ESTIMATES, ALL ESTIMATES MUST BE SUBMITTED TO A QUALIFIED ESTIMATE REPAIR AUDIT FACILITY (SUCH AS N.A.I.B.) TO DOCUMENT THE REASONABLENESS OF SUCH ESTIMATE, AND TO ACHIEVE AN AGREED REPAIR PRICE WITH THE REPAIR FACILITY OF THE OWNER'S CHOICE. In all cases of claims for property damage in excess of $1,000.00, independent damage appraisers must be utilized to detail the scope of damages resulting from the alleged incident, and to obtain an agreed repair price with a repair facility of the property owner's choice.

Claims for loss of use must be supported by written documentation. When it is necessary to procure a temporary replacement vehicle to control the damages claimed, such replacement vehicle must be arranged on behalf of our client, clearly identifying our client as the party responsible for payment of the charges associated with the replacement vehicle. Claim files must document the authorized length of the replacement vehicle's service, as well as the daily rate agreed to by the rental company and CCMI on our client's behalf. Documentation supporting the authorized extension of temporary replacement vehicles must be contained in the claim file. At no time will other loss of use type claims (such as "down-time") be considered without written, verifiable documentation relative to the amount and type of such claim being contained in the claim file. Absent of specific state procedural guidelines (such as is currently present in North Carolina) Loss of Value type claims will not be considered unless written, verifiable, expert testimony has been offered which clearly identifies the scope of the loss of value as it relates to the subject claim.

It is Corporate Claims Management's responsibility to bring about cost-effective, good faith resolutions to all claims that are presented to our clients. Claim settlements can only be offered in line with documentation provided and supported by the evidence of fault or responsibility of our client. At no time will ex gratia payments be allowed by any Corporate Claims Management employee. "Cost of Defense" settlements, in an amount over the actual value range of the subject claim, are strongly discouraged, and can only be offered with the express permission of the client.


Top

 

Claim File Expectations Trade Show Dates Our People Why CCMI
© 2017 Corporate Claims Management Inc.
A Patriot National Company • We Find Solutions
Privacy Policy