CLAIMS ADMINISTRATION SERVICE STANDARDS

 

Central Claims, LLC was founded on a theory that prompt, quality claim service delivered at a reasonable cost would provide a greatly needed service to our clients.  Central Claims, LLC strives to provide a quality product, promptly, at a competitive price through the use of well-trained personnel. 

 

Central Claims, LLC endeavors to adhere to the following service time requirements, which are applicable to all types of claims:

 

I. SERVICE TIME REQUIREMENTS


A.  Contact/Activity - 

1. Initial Contacts - Essential contacts should be initiated within 24 hours after receipt of the assignment. Contacts will be in person or by telephone depending on severity of exposure. Contacts via mail will be utilized in only those instances where personal contact is impossible or clearly not warranted.
 

2. Investigation - Regardless of the type of case received, concrete activity, substantiated by some form of evidence reflected in the file, will be accomplished within three working days following receipt of the     assignment.  Sufficient investigation will include those activities evidence necessary to allow the adjuster to properly evaluate the merits of the case and to provide the client with sound recommendations for each evaluation and ultimate conclusion.
 

3. Evaluation - With a 14 day requirement for completing an essential investigation, sufficient information should be available to allow the adjuster to reach a reasonable conclusion regarding coverage/liability and estimated damages. Sufficient investigation will include those activities/evidence necessary to allow the adjuster to properly evaluate the merits of the case and to provide the client with sound recommendations for each evaluation and ultimate conclusion.
 

B.  Reporting Requirements - 
 

1. Acknowledgement - Clients who require an immediate acknowledgement after receipt of assignment will receive one as determined in the terms of agreement.
 

2. First reports - Should be completed within a maximum of 7 calendar days after receipt of the assignment.  A First Report is defined as a typed or handwritten report reflecting concrete activity having taken place. In the case of vehicle appraisals, if the appraisal is not completed within 3 working days following receipt of the assignment, status letter will be forwarded indicating the reason for delay.
 

3. Subsequent Reports - All subsequent reports will be reported to the client at maximum intervals of 30 days unless otherwise specified by the client.  The only    exception to this would be on those files, which have been placed on a reporting diary of longer duration, and such duration is specifically stated in the previous     report. Timing of subsequent reports will be on individual basis according to the seriousness and urgency of the circumstances involved, which may justify     reporting intervals of less than 30 days.
 

4. Client Inquiries - All client inquiries will be responded to and appropriate action taken, within 7 days after receipt of the inquiry.
 

II. QUALITY CONTROL MECHANISMS
 

A. Injury Control/Management - Injury control necessitates the gathering and updating of adequate medical information to evaluate the severity of the injury involved, the prognosis, the need for personal contact, the determination of ongoing disability, the need for an Independent Medical Examination (with authorization), the need for possible modified work duties, rehabilitation evaluation, activity checks, etc.
 

B. Additional Investigation Planned - All reports will indicate the additional work planned by the adjuster, which will be necessary to bring the file handling to a conclusion.
 

C.  File Documentation - All contacts and activities conducted during the handling of a file will be documented. To facilitate documentation, all claims progress is documented by listing all activities to be recorded in a chronological order. A service bill itemization will be stapled to the left inside cover of every property file and all activities, mileage and expenses will be recorded on this form in a chronological order. A Compensation Payment Form will be stapled to the left inside cover of every Workers Compensation Indemnity file and all payments will be recorded on this form in chronological order as the payments are made.
 

D.  Index Bureau Reports - An Index Bureau Report will be completed on all injuries (excluding Workers Compensation Medical only).
 

E.  Property Insurance Loss Register - The Property Insurance Loss Register is a computerized system designed to reduce suspected arson and/or fraud losses.  Property Insurance Loss Register forms will be completed and filed on all applicable losses with proper advises to the client.
 

F. Checks/Drafts - All counter-falls for any check issued will be distributed appropriately in accordance with the client's instruction on the same date that the check is issued.  Only personnel having signature authority may sign checks.
 

G. Law Suits/Petitions - If suit papers and/or petitions are delivered to any personnel in any office, they will immediately be referred to the Manager or Adjuster in charge. The Manager or Adjuster of that office will immediately pull the file to which the suit papers refer and make certain a report goes forward to the client the same date. A telephone call will also be made to the client at the same time, alerting them to the fact that suit papers have been received and requesting further instructions. Date and method of service should be ascertained.  Ultimate responsibility for the handling of suit papers is that of the Claims Manager or Adjuster in charge.  
 

H.  Claim Supervision -        
 

1. Initial Investigation - Upon assignment of a new case (excluding Med-only and Appraisals) to Property/Casualty Adjusters (and other adjusters in accordance to their ability and/or the complexity of the assignment) a Supervisor/Assistant Manager/ Manager will first outline on the assignment sheet (or attachment) the items of the initial investigation to be conducted by the Adjuster.
 

2. 7 Day Futurity - Every assignment (excluding straight appraisal and W/C Med-only) received in our office will be placed on a 7 day futurity whereby, that file will be reviewed within a 7 day period of time to assure compliance with investigation and reporting standards.
 

3. Adjuster Futurity Review - No claims handling personnel would be totally self-supervising.  All claims handling personnel need, and will receive supervision on a regular basis.  All claims files will be reviewed on a monthly futurity review by the Claims Manager.  
 

4. Appraisal Futurity - Our office will maintain an appraisal review system on a 72-hour basis in order to assure compliance with the appraisal service time requirements.
 

5. Compliance - After a futurity review has been completed and forwarded to the adjuster/appraiser, it is that person's responsibility to review and follow the comments and recommendations provided therein.
 

6. Report Content - To achieve adequacy and accuracy of a report content, a Manager, Assistant Manager, Supervisor or Adjuster in charge is required to review (prior to  mailing) all reports to clients by adjusters.
 

III. RESERVES 

   

It is the ultimate goal of Central Claims, LLC whenever possible to stabilize the reserves on each exposure within 12 months from the date of accident, or sooner. Clients are provided with a prompt initial reserve recommendation as to the maximum potential exposure of each claim based upon the initial information then available.

 

Concomitant with information being developed as factual investigation continues reserves are reviewed and revisions made with consideration being given to coverage, legal liability, medical evidence, damages, subrogation, and collateral source factors where realistically applicable.

 

Reserves will be reviewed at maximum intervals of 30 days and, revisions made if necessary, throughout the handling of a file.

 

Workers Compensation Reserves Work Sheets will be completed on all indemnity cases which remain open 60 days or longer and again if the file remains open after a period of 11 months.

 

Bodily Injury Reserve Work Sheets will be completed on each Bodily Injury case which remains open for 60 days or longer and again if the file remains open after a period of 11 months. 

 

Initial establishment or subsequent revisions of reserves in excess of $2,000 per claimant, require the approval of either the Manager or the Adjuster in charge. 

 

IV. ETHICS
 

A.  Statement of Principals - All Central Claims, LLC personnel will abide in every respect by the Statement of Principals on respective rights and duties of lawyers, insurance companies, and adjusters relating to the business of adjusting insurance claims as adopted by the National Conference of lawyers, insurance companies and adjusters.
B.  Unfair Claim Practices - Central Claims, LLC is pledged to honest, fair, and prompt claim disposition. No employee will knowingly engage in unfair claims practices.

 

In 1971, the National Association of Insurance Commissions proclaimed a model Unfair Trade Practice or Act, which Central Claims, LLC recognizes in all instances in all jurisdictions. Legislatures in nearly every state have considered the recommendations of the Model Act, and many states have either completely rewritten the Unfair Trade Practices Act or have revised them or passed separate statues adopting some or all the recommendations in the Model Act.

                                       

C.  Gifts - At no time and under no circumstances will an employee of Central Claims, LLC accept a gift from anyone with whom we have a business relationship.   Anyone violating such instructions or accepting such gifts may be subject to discharge.  Any gifts received from any source should be immediately returned to the donor with courteous expression of appreciation but with a statement that company policy will not permit the acceptance of such gifts.
 

D.  Honesty - As far as Central Claims LLC is concerned there is no place in the company for an employee who is dishonest in any degree. Our policy is clear:  Dishonesty in any form will subject an employee to instant dismissal and possible prosecution.

E.  Conflicts of Interest - To avoid a conflict of interest, the rule is that we must accept the first case assigned and courteously refuse subsequent assignment by any other client related to the same case.  If a conflict of interest case does arise in the office, we are to immediately notify both clients by telephone. If either client objects to us handling for the other client, we must immediately cease handling for both clients.  We must then write to both clients advising them of the conflict and confirm the fact that we are closing both files and send to the clients whatever investigation has been completed with the request they make an assignment to other adjusting facilities. If both clients agree that we may handle both sides of the case, we must immediately write to both clients and confirm the telephone conservation and the fact they agree for us to handle both sides of the case. This Conflict of Interest Rule applies to assignments within our office. If a Conflict of Interest arises in a case being supervised by our office we immediately notify you of this conflict.

F.  Salvage - No employee of Central Claims, LLC is allowed to buy or bid on salvage involved in any claim file being handled by Central Claims LLC, or otherwise engage in salvage business without the permission of the client. Violation may subject the employee to discharge.


At no time and under no circumstances will a Central Claims, LLC, employee accept cash in payment for any salvage proceeds payable to our client.  All salvage proceeds must be accepted only in the form of a check or money order.  
 

G.  Subrogation Letters and Demands - Under the unauthorized practice of law statutes in every state it is unlawful for a corporation to practice law and all Central Claims, LLC, personnel must be alert to the thinly defined line between the handling of claims and the practicing of law.  On those cases involving subrogation, we will investigate the facts, determine the financial position of the adverse party insofar as is possible, we will ascertain the name of the insurance company of the adverse party, if insured, and will furnish this information to our client. We will not, under any circumstance, write a 'demand letter, however, we can and will place the adverse party on notice as to the interest of our client and such letter will in no way assess liability. 
 

Services Provided - 


We offer diversified claim services into full Property Loss Adjusting to include Fire and Allied lines, Inland Marine, Environmental Pollution, Business Interruption, Time Element Losses, Warranty Inspections and Catastrophic Losses, under three pre-designated service packages – full Adjustment Service, Agreed Price Appraisal, and   Damage/Condition Surveys. We also offer full Material Damage Appraisal Services to handle full or partial assignments for appraisals on automobiles, trucks, motorcycles, motor homes, pleasure craft and all types of heavy equipment. Quality control of our property adjusters is assured through our Claims Management.  The same can be said for quality control of our material damage appraisers, whose work product is strictly supervised by our Claims Management. 

 

Whether the assignment is a freeway accident, industrial explosion, airplane crash or a rampaging hurricane, Central Claims, LLC can provide the necessary claims expertise to service the insurance or self-insured industry.
 

FILE RETENTION AND DESTRUCTION POLICY
 

Liability Files Destroyed 2 years after Statute of Limitations has tolled.
 

I. Exceptions 
 

A.  Suits - Retain until expiration of appellate process, then destroy.
   

B.  Mental Incompetence - Retain indefinitely.
 

C. Infant (minor claims) - Retain until infant reaches majority plus applicable statute of limitations plus two years.
 

First Party Claims, Subrogation/Arbitration, Incident
 

Reports and bod losses will be destroyed one year after file closing.
 

I. Exceptions 
 

A.  Suits - Retain until expiration of appellate process, then destroy.
 

B.  Prevailing Statute - Prevailing statute precludes destruction in one year. 
 

WORKERS' COMPENSATION CLAIMS
 

Medical only claims, excluding occupational disease claims, destroyed 6 months after applicable Statute of Limitations have expired.
 

I.  Exceptions
 

A.  Prevailing Statute – Prevailing statute precludes destruction in six months. Other than medical only claims, excluding occupational disease claims: Destroy one year after applicable Statute of Limitations has tolled. 
 

B.  Formal or Informal Hearing Level Claims - Retain until expiration of appellate process, then destroy.
 

C.  Prevailing Statute – Prevailing statute precludes destruction in one year.
 

OCCUPATIONAL DISEASE CLAIMS
 

Destroy 4 years after applicable Statute of Limitations has tolled.
 

HISTORY AND ORGANIZATION
 

Central Claims, LLC was founded in 1964 by James I. Jones and has incorporated under the laws of the State of Louisiana.  All stock continues to be held by Dale Jones.  The company operates in New Orleans, Louisiana and is staffed by forty employees. 

 

Dale Jones, President and Claims Manager head the corporation’s organizational structure. We offer Risk Management Services, Property, Casualty, and Catastrophic Claims handling services. 

 

We adhere strictly to the statements or principals agreed upon by the American Bar Association in insurance industry and adopted by the American Bar Conference Committee on Adjusters on June 8, 1939, with subsequent amendments.