Deadlines
What is the deadline to serve Insurer Examination reports?
10 days from the date we received the reports
30 year old single female was a passenger in her fathers vehicle at the time of loss, she has her own insurance with Wawanesa but has sent an OCF-1 to Definity. what kind of investigation is needed?
Priority Investigation
How long is the max Non Earner Benefit payable for?
104 weeks
How often should you be calling unrepresented customers?
At least every 60 days or anytime you deny something on the claim
When does the insured need to be notified for an IE?
Not later than 5 business days before scheduled Assessment
What are some Red Flag examples to trigger an SIU investigation?
1. Address Misrepresentation
2. Late Report
3. Use of vehicle for Work
4. Incident/ accident
What calculating method is used when paying Attendant Care invoices?
Malitsky method
What is the most important question you should be asking customers in the Initial Call out?
How are you?
When is an invoice considered late if payment is not made?
30 days after receiving the invoice
What are some Red Flags for Late reporting?
1. If claim was not reported within 7 days of loss
2. OCF-1 was not submitted within 30 days of it being provided to the customer
3. Injuries were not reported when the Pd claim was opened
Customer broke his glasses during the accident, what section of the SABS discusses this benefit?
Section 24-
Damage to clothing, glasses, hearing aids, etc.
24. The insurer shall pay for all reasonable expenses incurred by or on behalf of an insured person in repairing or replacing the following:
1. Clothing worn by the insured person at the time of the accident that was lost or damaged as a result of the accident.
2. Prescription eyewear, dentures, hearing aids, prostheses and other medical or dental devices that were lost or damaged as a result of the accident. O. Reg. 34/10, s. 24.
What is the expectation for when an Initial call out should be completed?
What is the timeline for the death benefit to be payable, when an insured person dies as result of an accident.
The death benefit is payable if the death occurs within 180 days after the accident
What happens after Loss Transfer Liability is accepted by Third Party? Who pays for the claim?
Under certain circumstances, First Party Insurer's may be reimbursed by the third party insurer for all or part of the claim for anything above $2000.
If Loss transfer applies on a claim and is missed, it is considered leakage. Once LT is accepted by TP, a task must be created so the LT adjuster can send indemnification requests.
What changes in the disability test for IRB post 104 weeks?
The Disability test changes from substantial inability to Complete Inability
If a new customer has not started treatment yet, what should you as the adjuster offer to do?
Arrange a PPN referral for a clinic close to them