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Home / Home / Anatomy of a Claim

Anatomy of a Claim


That is the longest weblog publish I’ve made thus far. It is likely to be extra of a novella than a weblog publish. In my single weblog publish final week about buyer loyalty, I discussed that I had been shopping for my very own insurance since 1973. Throughout that point, I’ve by no means had a private auto declare (knock on wooden). And, till a modest twister declare a number of years in the past, I had solely had one owners declare. In that declare, I wasn’t in search of cash as a result of I doubted I had any important property injury…I used to be in search of assist in figuring out a water intrusion drawback and getting it fastened.

My expertise resulted within the following article I wrote over 20 years in the past for the Insurors of Tennessee journal the place I labored and it additionally prompted me to create a seminar with my co-conspirator John Eubank, CPCU, ARM known as “Easy methods to Battle an Adjuster…and Win Each Time!” (There’s a story behind the title of this seminar that I’ll share in one other weblog publish.) So, with out additional ado, right here is my first declare expertise story….

Anatomy of a Declare

It was a darkish and stormy evening. A drip rang out…

It was certain to occur in the end…my first declare. Though I spend a major period of time helping brokers in resolving claims issues, I had not had a declare myself in 21 years of buying auto and owners insurance. In mid-November, my spouse and I had organized for the carpeting in our dwelling to get replaced. When the outdated carpeting was eliminated in the lounge, we found a big black stain on the ground between the fireside and window.

It was raining that day, so sticking a finger between the flooring and baseboard shortly revealed a puddle of water. Someway, water was getting in from the surface and had clearly prompted injury—the extent was unknown, nor did we all know how lengthy the issue had existed, since there was no seen proof of harm when the carpet was in place.

At that cut-off date, I used to be much less involved about any insurance proceeds than I used to be in getting the issue corrected and figuring out if there was any structural injury. As a minimum, I figured the “specialists” within the claims division of my insurer may refer me to a reliable contractor. So, I known as my agent and reported the declare. I’ve to say that the method went easily and that afternoon I obtained a name from the claims division of my insurer.

The claims rep suggested that the adjuster can be calling me quickly to rearrange to examine the injury and, positive sufficient, inside the hour, an unbiased adjuster known as and we scheduled an appointment for the subsequent day. I assumed to myself, “Not dangerous, we’ll have this taken care of in brief order.” Little did I do know.

The adjuster confirmed up about 30-45 minutes late…he bought misplaced. That ought to have been the tip-off that this wouldn’t be such a easy trip. After the compulsory ‘how do you do’s’, one of many first issues out of the adjuster’s mouth was, “ this in all probability gained’t be lined.” Extra on this later.

I had the carpet pulled again from the baseboard space and had caught a paper towel between the baseboard and ground to indicate how moist the realm was. I supplied to tug the carpet again additional to indicate him the scale of the water spot and mildew, however he stated that wouldn’t be needed—I questioned how he may verify the character and extent of the injury with out it—though he did poke across the baseboard with a ballpoint pen and proclaimed that I had a leak someplace. A revelation!

He then bought a ladder out of his automotive, climbed to the eave, seemed across the roof, and said that I in all probability had a leak: (a) between the vinyl siding and exterior wall, originating from (1) the chimney, (2) gutter or (3) window molding, (b) across the chimney flashing, (c) from below a foul shingle, (d) from puddling floor water, or (e) from unknown sources.

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He reiterated in an authoritative voice that in all probability, after all, not one of the inside injury was lined by my owners coverage—solely windblown shingles—however he would flip the report in anyway. His advice was, “It’s worthwhile to get this fastened.” And, after all, he identified that my insurance didn’t pay “for that form of factor.”

I questioned the place he had obtained his insurance coaching since he gave the impression to be making an official willpower that there was no protection. Definitely, there was no have to query his information or experience since he was assembly all state necessities for claims adjusters—he had a clipboard, flashlight and ladder. And, I virtually forgot, his indispensable mixture ballpoint pen / wooden rot testing system.

[Be aware: Has anybody ever questioned why you must be licensed and meet state-mandated instructional requirements with a view to promote insurance…however you don’t should have any credentials (not less than in our state) to regulate an insurance declare? However, I’ll save this diatribe for an additional time.]

Earlier than leaving, the adjuster jogged my memory one final time that this loss in all probability wasn’t lined. I lastly requested him why, and he mumbled one thing about rainstorms and damaged home windows, and a few exclusions for “water injury” and “leakage.” He additionally recommended that I get this “taken care of straight away” because the coverage required me to take action and wouldn’t pay for any subsequent injury—an accurate assertion—though I questioned how the coverage may require me to do one thing relating to a loss that wasn’t lined anyway. However I didn’t belabor the difficulty and wished him a pleasant day. As he waived goodbye, he stated somebody can be contacting me quickly.

I don’t know his definition of quickly, however “quickly,” in claims-adjusting parlance, apparently means not less than ten days as a result of that’s after I lastly heard from somebody…after a number of cellphone calls to my agent and insurer.

I had really known as my agent after per week to advise that I hadn’t heard from anybody and I nonetheless had a small lake in my front room from a latest rainstorm. My CSR instructed me she’d have to make one other declare report since this was one other “prevalence” and, after all, there can be one other deductible.

This is a wonderful philosophy from the insurer’s standpoint—delay a declare settlement and don’t help in any means in correcting the issue. Then, each time it rains there might be one other deductible, with solely minimal extra injury. Should you can put it off lengthy sufficient, you may accumulate sufficient in deductibles to by no means should pay a declare! In fact, I’m being facetious…the adjuster would by no means be taught such a factor, significantly, I’m satisfied, because the adjuster had by no means been taught a lot of something. [Note: As you be able to tell, the seething has started.]

I instructed her to neglect it and simply give me a advice on a contractor. She gave me the identify of a contractor, I known as them, and so they instructed me they didn’t “idiot round” with restore work, however they did give me the identify of somebody who apparently does “idiot round.”

Earlier than I may contact the really useful contractor’s really useful contractor, a newly-assigned firm claims rep known as about my “second” declare and I instructed him I used to be simply kidding and to neglect it. Shortly thereafter, the unique unbiased adjuster known as and I instructed him to neglect it too, though we did have a short, however cordial, philosophical dialogue about insurance exclusions and situations (I’ll talk about this later).

I lastly reached, after a number of cellphone calls, the really useful contractor’s really useful contractor. He got here to the home and proclaimed it have to be a chimney flashing drawback as a result of…it normally is. He stated I would want to get the vinyl siding contractor out to take away all the siding from across the chimney and off the again of the home, then he would redo all the flashing (in addition to another work that he famous I wanted throughout his inspection), then I may get the siding firm to switch all the pieces. If that didn’t work, he’d attempt one thing else.

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Within the meantime, my spouse had gotten the identify of a roofing contractor from our five-year-old son’s former baby-sitter’s son’s development firm receptionist. This man got here out 3 times and did some sealing and caulking across the roof and siding. The leak bought worse. After his third go to, he indignantly proclaimed that the roof was fantastic—he’d fastened it—so it have to be the window molding that wanted “fixin’,” and that we must always contact the vinyl siding folks. We did.

The vinyl siding people gave us the identify of a man who does roofing and siding. After a half-dozen cellphone calls, he lastly got here out one weekend whereas we had been out of city to examine the roof and stated he would give us a name, after we returned, along with his analysis. He by no means known as.

About that point, the really useful contractor’s really useful contractor known as again to see if we had been prepared to start our contributions to his retirement fund. We instructed him concerning the baby-sitter’s son’s contractor’s willpower that it was a window molding drawback. He stated that man didn’t know what he was speaking about and he may see that within the sloppy work he did when he tried to seal across the chimney and siding. It does look terrible, so we thought possibly this man is aware of what he’s speaking about.

Within the meantime, we bought a verify from the insurer! The quantity was a whopping $20 to pay for the damages (in extra of the deductible) that the unbiased adjuster stated weren’t lined to start with. At this level, I didn’t need a verify—all I needed was to repair the issue. We didn’t even know what was responsible for the leak, what the damages had been, or what it could value to restore the leak.

The declare report, although, was attention-grabbing. The adjuster’s analysis was “Downside: Not any flashing round space of roof close to chimney.” In truth, the chimney is flashed, however how will you argue with a person with a clipboard, flashlight, ladder, and a wood-rot-testing ballpoint pen?

The estimate parts had been all in $25 and $100 increments—very scientific. I may have given them precise invoices to-date if somebody had ever requested…and they’d have realized that they had been lower than my deductible. Included within the estimate was $100 to “re-lay and clear” the carpet. If the adjuster had simply pulled again the carpet a number of inches or listened to something I stated, he would have found that we had simply laid new carpeting (that’s how we found the leak) and there was no expense really incurred.

Now, again to the vinyl siding firm really useful contractor. He didn’t name, so I known as him…fourteen occasions (no kidding). I known as his workplace. I known as his dwelling. I beeped him. I known as at 5:30 a.m. and 10:30 p.m. I talked to his secretary, his spouse, two of his youngsters, and a few man with a Turkish accent that I believe was ransacking his home (solely kidding concerning the final one). Lastly, I gave my spouse his quantity(s) and he or she, after all, bought him on the primary try.

He stated he thought he knew what the issue was and, in that case, may appropriate it shortly. If that didn’t work, he’d attempt one thing else. At the least it didn’t sound like he supposed to rebuild your complete roof. Lastly, he got here out and made some kind of adjustment to the chimney cap and charged us $35. We’ve had 5 straight days of rain since then and the ground is as dry as a bone. It seems the issue has been corrected.

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Nonetheless, the unique adjuster had made it clear in our final cellphone dialog that restore prices are by no means lined—solely precise damages. However, in my specific case, even the damages, in keeping with the adjuster, are usually not lined, though the insurer should disagree since they despatched me a verify.

When the adjuster suggested me of his skilled opinion, I requested him few questions on my owners coverage. For instance, the place particularly did my coverage exclude this loss? What did the Further Protection 2.Cheap Repairs imply when it stated it could pay for “needed restore prices to guard in opposition to additional injury?” What’s the that means of Part I – Situation 2.d.? After a protracted pause, he stated I ought to discuss to the corporate as a result of, in his phrases, “Insurance coverage normally doesn’t cover your form of loss.”

Regardless of the declare report estimate, we nonetheless don’t but know what precise injury, if any, has been completed. We’re within the means of finding a contractor to find out if we have now any structural injury and arranging for a termite reinspection. Please pray for us.

Our out of pocket bills for all the restore estimates and work completed to cease the leak is someplace round $200 (nonetheless inside the deductible) and I’m anxious to see what occurs after I flip in these bills. Furthermore, God solely is aware of the price of this declare when it comes to the time concerned and the frustration endured. Whatever the consequence of this complete affair, it definitely has been a studying expertise.

First, I’ve realized that, although the response to a reported declare could be immediate and courteous, that also doesn’t imply that the declare itself might be settled expeditiously—significantly for those who’re coping with contractors.

Second, I’ve realized that some insurers appear extra involved about procedures, paperwork and paying (or not paying) claims than really serving to a buyer resolve an issue—it’s simpler handy out a verify than to really present any actual service.

Third, I’ve realized firsthand what brokers have instructed me for years—that there actually are folks on the market deciphering insurance contracts which are equally certified to carry out emergency tracheotomies—the outcomes typically appear about the identical. I’m wondering what number of insureds have had claims wrongfully denied as a result of an adjuster stated “We simply don’t cover these form of issues”?

Fourth, I’ve realized that claims adjusters say “in all probability” quite a bit.

What’s the ethical of this story? At this level, nothing about this incident appears “ethical,” however I can provide you one bit of recommendation that I plan on taking myself: improve your deductible. Due to this expertise, I plan to extend my owners deductible to not less than $1,000, pocket the financial savings, and deal with the issue myself subsequent time.


It has now been over a 12 months since this text was [originally] revealed. My home is dry…and I nonetheless have the $20 verify, uncashed and appropriate for framing. I determine it’s solely a matter of time earlier than this uncashed verify brings the insurance firm’s accounting system to its knees. This expertise has taught me a lot, and was a motivation in publishing this e book. Though I’m satisfied that my expertise was one thing of an aberration, and that the overwhelming majority of adjusters are extremely expert at what they do, brokers and shoppers will nonetheless proceed to come across comparable conditions…some a lot worse than mine.

Photograph by andrew steinmetz cc - Anatomy of a Claim

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