By Lisa R Hardin, CPCU, CPIW, AIC, AIS, ACS, AINS, CCLA, ACLA, CLP, DAE
Claims Specialist, Sentry Insurance
The entire insurance industry is built on the idea of a promise – in exchange for a premium payment, the insurance company promises to pay the insured if a covered event occurs. It’s the responsibility of the claims department to fulfill that promise, which makes claims handling one of the most noble of professions. We are the ‘Promise Keepers’.
There are as many different types of jobs in Claims as there are different types of policies sold, and more. Let’s look at what skills sets are best suited for a career in Claims.
People Skills – Claims is a customer service career at its core and can be confrontational at times. This is because there are limitations to the promise, and those limits are not always understood. Claims professionals are interacting with policyholders and claimants at a difficult time in their lives and most have never gone through the claims process before. Therefore, the ability to act with compassion and empathy, while accurately assessing the details of a claim is beneficial.
Analytical and Decision-Making Skills – Coverage analysis and investigation are part of every claim. Determining what happened and if it’s covered under the conditions of the promise made in the insurance contract requires a questioning mind and attention to detail. Recognizing patterns and learning to see the red flags that are indicators of fraud are also important. Making a decision based on the information you have today rather than waiting until you have every last document or expert opinion can be the difference between a settled claim and one that goes into litigation.
Time Management Skills – The plain truth is when you work in Claims you’ll never be “caught up”. There will always be phone calls to return, emails to send/reply to, new files that need prompt contacts made, reports to review, letters to write and payments to issue (settlements, vendor payments, medical bills, attorney fees etc.). The key is having the ability to prioritize your workload, recognize what needs to be done today, what can wait until tomorrow, and being prepared for all your plans to change.
Communication Skills – Claims professionals are often the only contact a policyholder or claimant may have with an insurance company. Communication via phone, email, and text is commonplace, but strong written and presentation skills are also necessary. Claims professionals must communicate, not only the neutral facts of a loss investigation and coverage terms, but they must also bring empathy, compassion, and an understanding perspective to their communications with those who have experienced loss.
Let’s look at some of the common career paths available in Claims.
Claims Call Center – May also be referred to as First Notice of Loss (FNOL). This is the claims department’s intake center where representatives establish new claims from information provided by policyholders, claimants, agents or other insurance carriers either by phone, fax, email or web submission. They may also act as the customer service line for the claims department directing incoming claim calls to the correct area. Attention to detail, keyboarding and good listening skills are highly sought after in these positions. This is a high-volume, entry-level area but is a good stepping-stone to other areas within the claims department.
Medical Bill Review – Jobs in this area range from entry-level positions reviewing bills for accuracy in diagnostic and procedure codes before authorizing and issuing payment on small medical only worker’s compensation or health insurance claims, to preparing chronologies and analyzing treatment to assist in determining causation and reasonableness of treatment in more complex liability claims. A strong medical background is necessary for higher-level positions.
Adjuster versus Appraiser – An appraiser’s job is to assess the value of something – the damage to an auto, a home, a piece of equipment or a piece of fine art or jewelry. Many insurance appraisers have a background in construction or automotive repair. An adjuster’s job is to assess coverage, damages and fault and ultimately make the decision on whether the claim is covered and how much is owed under the policy.
Field versus Desk Adjusters – As the names imply, the majority of a field adjuster’s work is done in person, out in the field, going to people’s homes/businesses, accident scenes etc., while the majority of a desk adjuster’s work is done from the office, or these days – a home office, but may include attending mediations or trials.
Public Adjuster – A public adjuster is often hired by a policyholder to help them with a large property claim, such as a house fire. They are a licensed fiduciary and a legal representative of the policyholder. They help the policyholder prepare detailed proof of loss statements and cost estimates to help prove their loss. They usually receive a percentage of the settlement as their payment.
Personal Lines Claims Adjusters – These adjusters generally handle claims involving homeowner’s policies and/or personal auto policies. Typical claims involve damage to the home or its contents from some physical loss such as fire, smoke, hail or freezing pipes, a burglary or someone being injured on the homeowner’s property, and auto accident claims. These adjusters may also handle claims involving recreational vehicles such as boats, RVs or ATVs.
Commercial Lines Adjusters – Commercial claims are generally separated into workers’ compensation and property and casualty lines. Adjusters handling workers’ compensation claims deal with employees who are injured on the job. Their contacts include the injured worker, the employer, medical providers, nurse case managers and, in some cases, attorneys.
Commercial property adjusters handle the same types of physical losses that personal lines adjusters do, but on a larger scale, for businesses. In addition to physical damage to a building and its contents, other exposures could include Loss of Business Income, Loss of Rents, and Payroll Coverage if the business is shut down due to a covered loss.
Casualty, or Liability adjusters handle claims involving a business’s liability to others. This includes property damage and/or injuries to others that occur on their premises, caused by their work or their product and auto accidents. But it also includes claims involving employment-related practices; copyright or trademark infringement; claims of defamation, libel or slander; and errors in administering employee benefits programs.
Umbrella/Excess Adjusters – Also known as surplus lines adjusters. Their policies layer over the top of primary policies and provide excess/surplus coverage after the primary policies have exhausted their limits. The claims these adjusters handle are complex in nature simply because they’ve breached the primary layer of coverage. They will generally involve multiple claimants, severe injuries with high dollar damage amounts, or both.
Independent Adjusters -An independent adjuster usually is a general lines adjuster who will handle both personal and commercial exposures either on behalf of an insurer or a self-insured business, rather than being employed directly by a single insurance carrier. They may be self-employed or work for a large adjusting firm such as Frontier Adjusters, Crawford & Company or David Morse & Associates.
Many self-insured businesses will hire a large, independent adjusting firm to be their third-party administrator or TPA to handle their claims rather than doing it internally. A desk adjuster may hire an independent adjuster to conduct a scene investigation or property estimate if their company doesn’t have coverage in the area. Independent adjusters are also widely used in the event of a catastrophic claim impacting an entire region, where an insurance carrier may not have sufficient local staff of their own to service the inflated volume of claims.
Subrogation Adjusters – Instead of paying money out, a subrogation adjuster’s job is to recover money for the insurance carrier. Recovery can come directly from other responsible parties, but most likely it comes from the responsible party’s insurance carrier. A subrogation recovery is triggered when an insurance carrier pays a loss on behalf of their policyholder that another party is legally responsible to pay, such as when the insurer pays for the damage to a policyholder’s car under the collision coverage in a rear-end accident. The insurer seeks recovery of that payment from the at-fault driver (or their insurance company). Another large portion of subrogation claims deals with recovery of workers’ compensation payments when an employee is injured in an auto accident or due to a faulty product.
Special Investigations Unit (SIU) – The FBI estimates that non-medical insurance fraud costs insurance carriers over $40 billion each year. While SIU investigators are responsible for investigating all aspects of insurance fraud within a company, the focus here is on claims. SIU Departments assist adjusters to identify, investigate, and defeat insurance fraud. Members of the SIU Department come from both insurance and law enforcement backgrounds, but with the use of technology and predictive analytics, a background in IT and data science is also helpful. SIU investigators investigate suspicious claims, work closely with local, state and federal government entities to assist in the prosecution of insurance fraud suspects and educate adjusters on the fraud red flags to help them identify potential fraudulent claims early.
You’re probably thinking “why in the world would anyone pursue a career in a field where the work is endless, you feel like you’re always putting out dumpster fires and people yell at you?”. Most claims professionals will tell you – despite everything, the work is interesting and fulfilling no matter how many times someone yells at you. No two days are alike, just as no two claims are alike. And the stories we can tell. Don’t get us started.
Every day presents new challenges and opportunities to help others get their life back to the way it was “before” or as close as an insurance settlement check can make it. That check represents someone being able to repair their car, rebuild their house, pay medical bills or even send their child to college. Claims professionals help people push the “reset” button when the unexpected happens. They are the ones who help you replace the “stuff” you buy insurance to cover.
Claims professionals also help protect your assets. When a claim is made against you, an adjuster has the responsibility to fully investigate the loss and determine who was wat at fault. If you weren’t responsible the adjuster denies the claim, and if necessary, hires the appropriate legal defense team to fight for you. However, if it was your fault, the adjuster works to determine and pay a fair and reasonable settlement, so you don’t have to cash out your 401(k).
Claims professionals come from all walks of life – straight out of college with degrees from business to music; or as a second or even third career with backgrounds in retail and other customer-service-based jobs, the medical field, teachers, construction, and law enforcement – the list is endless. But the one thing they all have in common is a desire to help others.
If insurance is the promise that the insurance company will pay when a covered loss happens, whether small or catastrophic, then it’s the Claims Professionals job, as the Promise Keepers, to make the promise a reality. We are the ones who make the words of the insurance contract mean something. We bring them to life when we investigate a claim, determine a loss is covered and issue the settlement payment. It’s a career spent helping people get back on their feet after an unexpected loss – that’s what job as a Claims Professional is all about. And that’s why I’ve devoted more than 25 years to handling claims and can’t see myself doing anything else.
Lisa R Hardin, CPCU, CPIW, AIC, AIS, ACS, AINS, CCLA, ACLA, CLP, DAE
Claims Specialist, Sentry Insurance
Lisa graduated from the University of Wisconsin-Stevens Point in 1988 with a B.S in Business Administration-Finance. She’s worked for Sentry Insurance since 1990 and is currently a claims specialist handling large liability losses for Sentry’s national accounts. Lisa joined IAIP in 1994 as a member of Mid-Wisconsin Insurance Association. She is currently a Member-at-Large from Wisconsin and is serving on the NAIW Legacy Foundation Board of Directors.