How to give claims advice without being a claims adjustor

Hawaii Agent

Expert
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I always have clients asking if XYZ is covered. How do you guys address this without it being viewed as claims advice? Is there a standard phrase that you use? I'm looking for help from the experts!
 
Take the customers info and you call the claims dept without identifying the customer if you are not sure. Dont know how long you have been an agent but you should have a sense of what is and what is not covered.
 
I've been an independent agent for 10+ years, but a lot of people ask preemptive claims questions. I get questions asked by prospects and I am trying to make sure that I'm not put into an E&O situation. I typically let them know that all claims are handled on a case by case basis, but I'm wondering if you guys have better phraseology that can get the point across that I'm not giving any claims advice
 
I've been an independent agent for 10+ years, but a lot of people ask preemptive claims questions. I get questions asked by prospects and I am trying to make sure that I'm not put into an E&O situation. I typically let them know that all claims are handled on a case by case basis, but I'm wondering if you guys have better phraseology that can get the point across that I'm not giving any claims advice

Understanding what will be covered seems easier than trying to navigate & be a psychic to figure out how filing a claim may impact their rate today. And then read the future as to what claims they may or may not have in the future & how they will impact premiums or discounts. That seems to be harder than the past along with figuring out or explaining how credit based insurance scores work or are calculated.

Coverages or claim what ifs seem to be the simple part of the business today. Sorry I was no help, but it struck me that pricing & algorithms are harder to understand & explain
 
I am not a P&C agent, but in my opinion, answering a "what if" claims question is a snake pit.

In my 45 years in the health insurance business I have never once answered a direct claim question with a definitive answer and never will. I have no problem explaining contractual provisions but there are far too many variables in claims adjudication to, in my opinion, give a direct answer.

The policy explains what is and is not covered. Policies are also heavily infused with legal mumbo jumbo (weasel language) that make it possible to pay or deny almost any claim.

It's like approaching a doctor at a party, describing symptoms, and asking them to render a diagnosis.

Nothing good can come from speculating about the answer to "what if"
 
During my years as a claim rep I had many policyholders say "My agent told me." Then I would often have to say "Your agent was wrong. I'll read you what it says in your policy."

It's best for an agent to be cautious about answering "what if" coverage questions unless he/she can point to a place in a policy and say "Here's what your policy says about that."
 
During my years as a claim rep I had many policyholders say "My agent told me." Then I would often have to say "Your agent was wrong. I'll read you what it says in your policy."

It's best for an agent to be cautious about answering "what if" coverage questions unless he/she can point to a place in a policy and say "Here's what your policy says about that."

I absolutely agree! That's why I never say XYZ is covered. Even if I do have the policy language, I don't dare to interpret it for the insured. I send them the policy or endorsement with the verbiage (which sucks for them because they need to learn to read legaleze to figure it out).
 
At this point in the discussion it is appropriate to present, for your amusement, the Plain English Homeowners Policy:


PLAIN ENGLISH HOMEOWNERS POLICY

For a period of ___year(s) ending promptly at midnight, Standard time on ________________

Property Location:______________________________

AMOUNT OF INSURANCE YOU BOUGHT: $___________________ BLANKET ON YOUR HOUSE, ALL THE ACCUMULATED FURNITURE AND STUFF INSIDE YOUR HOUSE, YOUR GARAGE (the one where you park your car, not Al's Body Shop) AND ANY OTHER SMALL BUILDING ON THE LOT, AND WHAT IT COSTS EXTRA TO LIVE WHEN YOUR HOUSE IS BURNED DOWN OR SOMETHING LIKE THAT HAPPENS, FOR SO LONG AS WE SAY IT'S OK.

WE ALSO WILL DEFEND YOU IN COURT IF SOMEBODY MAKES A CLAIM AGAINST YOU, OR PAY THE DAMAGES, AND WE'LL PAY THE MEDICAL BILLS OF SOME PEOPLE WHO GET HURT ACCIDENTALLY AT YOUR PLACE, OR SOME OTHER PLACE.

(We could spell it all out in detail, but you wouldn't understand one word of it anyway. We had to hire ten lawyers just to figure this out after we wrote it!)

CONDITIONS:

1. If anything happens and it looks like it's going to cost you money, call us right away and we'll tell you if we're apt to pay for it.

2. Our agent has already told you this is the new "all risk" policy, but even he doesn't know what he's selling, so if you have any questions, call or write to us, not some insurance salesman.

3. Don't lie to us about what happened or how much something cost or how new it is or how it never leaked before. If you try to snow us, we'll not only cancel this policy so fast it'll make your head swim, we'll pass the word around and you won't ever be able to get an insurance policy again short of the Hong Kong Mutual. There are so many regulations, and an Insurance Commissioner who thinks he's king, that we can't lie to you. So don't you give us any song and dance or we'll land on you hard.

4. Replacement Cost: forget it. You don't need it. We'll pay what we say is fair with or without any "Replacement Cost coverage," and we don't care what your neighbor's policy has on it.

5. The "AMOUNT OF INSURANCE YOU BOUGHT" listed above is the absolute cost we will pay no matter what your house and other stuff is worth or however many people sue you for any one accident, so you'd better be sure you have bought enough to cover the worst disaster that you can imagine. Don't depend on our agent for this! If he had any imagination, he'd find an honest occupation.

6. Don't bother us with a lot of questions about what is and isn't covered by this insurance. We'll tell you when you need to know. If we told you now you'd forget it in an hour, if you ever understood it in the first place.

7. YOUR DUTIES: (1) Pay the premium, and (2) call us right away when you think something's happened (don't try to analyze it, just call in.) That's all you gotta do. Don't try to get cute; see (3) above, in case you have forgotten already (which doesn't surprise us.)

8. If we think of any additional conditions, we'll let you know. By the way, if what happens involves a vehicle, airplane or boat or has to do with your job, forget it; don't call us; we don’t cover it.
 
Just about every claim is one data point away from denial. There is always the potential that the most obvious payable claim can be denied because of some specific exclusion, condition, status, action, or inaction - therefore any "advice" is not worth much.

A solid technique is to immediately state that you cannot answer their question, because you are not their agent and don't have all of the information. Then move over to a theoretical situation.
 
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