Use of Experts to Resolve Claims

A Video Explaining the Use of Experts to Resolve ClaimsShow more

When the investigation is complete the adjuster must determine if assistance is needed from liability experts, medical experts, or legal counsel, or if it is better to rely on the layperson’s understanding of physics, medicine, or other special areas involved in the particular case.

Because a bad faith claim challenges the reasonableness of an insurer’s conduct in investigating and adjusting a claim, the insurance company’s conduct is judged objectively, using proof of industry standards. [Travelers Ins. Co. v. Savio, 706 P.2d 1258, 1274 (Colo. 1985)].

In a case where nothing in the record convinced the court that jurors are familiar with the Boeckh Cost Guide or Xactimate or the how and when of its general use. The alleged negligence in this case involves technical knowledge of the insurance industry and industry practices. Expert testimony was required to establish the standard of care. Because the plaintiffs failed to provide the requisite expert testimony, there was insufficient proof concerning the standard of care. Thus, the jury’s verdict cannot be sustained. [Konrady v. Bremer Insurance Agencies, 639 N.W.2d 224, 249 Wis. 2d 489 (Wis. App., 2001)]

It is appropriate and, indeed, often required to use an expert to establish insurance industry standards at trial. The opinion of an independent, unbiased expert who is paid a reasonable fee can be helpful to the investigation.

The Independent Medical Examination (IME)

When a claimant claims an injury that does not agree with the facts of the incident claimed to have caused the injury, the adjuster will often seek the assistance of an Independent Medical Examiner (IME) to verify the extent of the claimed injury. The IME is usually a forensic physician or a chiropractor who has agreed to evaluate an injured person for a fee and is not involved in the treatment of the injured person.

In Pennsylvania, an insurer providing medical benefits to its insureds following an automobile accident did not have to establish good cause before the insureds were required to take physical examination administered by doctor of insurer’s choice, even though statute provided generally that insurer seeking to compel independent medical exam was required to show good cause; policy gave insurer right to order examination without establishing good cause. [Fleming v. CNA Ins. Companies, 409 Pa. Super. 285, 597 A.2d 1206 (1991)].

Although the insurer was not a party to the action the judge was so angered—and properly so—by the wrongful conduct of the insurer that he solicited the insured defendant to file a bad faith suit. To avoid charges of bad faith every insurer, and its personnel should apply the Golden Rule and treat every insured and claimant as they would expect to be treated by their insurer.

© 2021 – Barry Zalma

Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 52 years in the insurance business. He is available at http://www.zalma.com and zalma@zalma.com.

Mr. Zalma is the first recipient of the first annual Claims Magazine/ACE Legend Award.

Over the last 53 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.

Go to the podcast Zalma On Insurance at https://anchor.fm/barry-zalma; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ Read posts from Barry Zalma at https://parler.com/profile/Zalma/posts; and the last two issues of ZIFL at https://zalma.com/zalmas-insurance-fraud-letter-2/ podcast now available at https://podcasts.apple.com/us/podcast/zalma-on-insurance/id1509583809?uo=4