Frankel & Associates

Claim Review Criteria Why have a claims review? Claim costs are a large percentage of every insurance premium dollar. The difference between profit and loss to a company is often dependent on control of losses. Efficient and effective claim handling can be the difference in making an insurance company or self-insured program a success. How do we select files? The object of a claim review is to obtain a broad view of the claims handling process in a claims department. A stratified random sample is a method of selecting files to review in order to have a valid overview and cross sample of the claims handling. To obtain a random sample, claim files are picked arbitrarily to ensure that the claims operation is properly tested. Cases representing low, medium and high damage injuries as well as matters handled by various adjusters in the organization are reviewed. Do you have specific needs? Frankel & Associates tailors claims reviews and analyses to suit your needs. Although our claims review criteria has been developed to cover all essential details of a claim, we consider flexibility to be our hallmark. Our flexibility is to ensure your needs are dealt with specifically. We listen to you and gear the review to your issues. What do we look for in a claims review? Adequacy of Reserving Files are reviewed to evaluate the propriety of reserves based on the information gathered. The emphasis is placed on files not being over or under-reserved based on liability and damages. Thoroughness of Development We review claim files to determine whether the adjuster has: 1) considered all coverage issues; 2) conducted an investigation; 3) documented the file to adequately support liability, damages, defenses, immunities, apportionment and subrogation; 4) analyzed the file; and 5) appropriately closed the file. Controls Taken It is important for the adjuster controlling costs to make sure litigation management techniques are used to control legal expenses. Equally important is the significance of staying on top of medical rehabilitation situations. We evaluate whether malingering or fraud should be suspected and assess the actions taken by the adjuster to investigate the matter. When the case is in litigation, it is important to have up-to-date legal analysis. We review the files to make sure that defense attorney documentation is adequate. Appropriate Disposition of the Case As part of our review of the files, we assess whether a denial of the claim or settlement was appropriate. We evaluate the amount of payment in relationship to the liability and damage information to determine if payment was made within usual industry standards. Emphasis: "Flexible To Client Needs" Reviews are tailored to the need of the client. Where only reserves are in question, the review is geared to that issue. We Report Our Results Reports are made on our claim reviews, when requested, that show our findings, conclusions and recommendations.

Contact Information: Mitchell E. Frankel, J.D. Insurance Claims Consultant Frankel & Associates 1959 Rosewood Lane, Vacaville, CA 95687 Phone: (707) 451-2947 FAX: (707) 451-1494 Email: mitchfa4@gmail.com