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Professional Insurance Adjusting
At the turn of the century, insurance companies, in an application after profit, decimated their professional claims sta. They laid off experienced staff and replaced them with young, untrained and unprepared ones.
A virtual clerk replaced the old professional damage handler. Process and computers replaced skill and judgment.
Insurers intentionally forgot that the promises given in an insurance are kept by the professional tortfeasor. A professional tortfeasor is a cost-effective method of avoiding litigation.
The professional tortfeasor is an important part of the insurer's defense against litigation against insurers for breach of contract.
A staff of claims professionals dedicated to excellence in claims management an insurance company. Experience shows that professionals settle more claims for less money without any of the parties needing to involve advice. A satisfied insured or injured party who is satisfied with the outcome of his or her claim will never sue the insurer. Every investigation carried out on claims for damages shows that claims with an insured or injured party represented by an agent cost more than those where the agent is not involved.
Fast, efficient and professional claims management saves money and fulfills the promises made when the insurer sold the insurance.
Insurers who believe they can handle first- or third-party claims with young, inexperienced and cheap claims managers will be met by the cries of angry shareholders. Profits, thin as they are, will quickly move into negative territory. Punitive damages as punishment for handling claims in bad faith will deplete the reserves. Insurance companies will quickly question why they write insurance. Those who remain in the insurance industry will either adopt a program that requires excellence in claims management from each member of their claims staff, or they will fail.
Insurance is a business. It must change if it is to survive. It must reconsider the dismissal of experienced claims staff and reductions in training to save "costs".
Excellence in Claims Handling
Excellence in Claims Management is a program that can help insurers avoid accusations of bad faith in both the first and third
An insurer must understand that it can not satisfactorily fulfill the promises it makes to the Insured and the Fair Claims Practices Act found in almost every state, when dealing with applicants without excellence in claims handling. An insurer must work intelligently and vigorously to create a professional claims department.
Professionals in insurance claims are
- People who can read and understand the insurances issued by the insurer.
- They understand the promises in the insurance. and their duty, as the insurer of an insurer, to fulfill the promises made.
- They are all competent investigators.
- They have empathy and realize the difference between empathy and sympathy.
- They understand medicine related to traumatic injuries and
- They understand how to repair damage to real estate and movable property and the value of the repairs or property.
- An insurer whose compensation staff consists of people who are smaller than the insurance chambers will to be destroyed by costly and counterproductive litigation.
A Proposal to Create Claims Professionals
To avoid allegations of bad faith; to avoid punitive damages; to avoid losses; and in order to make a profit, the insurance companies must have claims personnel who are dedicated to excellence in claims management. This means that they will ensure that all the promises made in each policy are fulfilled by:
- Insurers who only employ professionals in insurance claims.
- Insurers who train non-life insurance professionals to become professionals in insurance claims.
- The insurance industry has for the past 25 years decimated the number of insurance compensation professionals for insurers to hire.
- If there are any experienced claims professionals in the insurer's staff, the insurer must nurture and nurture them. If no one is available, the insurer has no choice but to educate its people.
- Those who treat all insured and injured parties in good faith and fair treatment and provide excellent claims management must be honored with increased income and benefits.  The insurer must eliminate immediately those who do not provide excellent claims management from claims reporting staff.
What sources are available for training?
Insurance training is available nationwide via correspondence, at local colleges and universities and from law firms that will provide training as a marketing tool. None of these sources are aimed at insurance claims professionals. They provide the basic background information needed to begin the process of becoming an insurance professional. In that regard, I have created electronic injury management training programs available from experfy.com and another set of courses from illumeo.com.
An excellence in injury management program may include a series of web-based lectures supported by text materials such as my injury books available on amazon .com and via the insurance claims library on my website at https://zalma.com.
The web lectures must be supplemented with meetings between supervisors and claims staff on a regular basis to reinforce the information learned during the lectures.
In addition, the insurer must set up a regular claims review program to determine compliance with the subjects studied. There is no quick and easy solution. The training takes time. Learning takes longer. The insurer's management must support and strengthen the training on a regular basis.
The program for excellence in the claims management program requires a minimum of the following:
- The insurance policy – how to read and understand the agreement that forms the basis for each adjustment.
- The construction of the insurance policy.
- Torts including negligence, strict liability for damages and intentional damages.  Contract law including the insurance contract, the lease, the bill of lading, agreements without waiver, proof of loss, release and other damage-related contracts.
- The insured's liabilities.
- The insurer's obligations and obligations in a personal injury claim.
- The insured's obligations and obligations in a first party property claim.
- The insurer's obligations and obligations in a first party property claim.
- The thorough investigation.
- Basic investigation of a claim for a car accident.
- Basic investigation of a claim for a construction defect.
- Basic in the investigation of a claim for non-auto negligence.
- Basic investigation of a strict liability requirement.
- Basic examination of first-party property claims.
- The recorded statement from the first-party plaintiff. The recorded statement or interview of a third party applicant.
- The insured's recorded statement.
- The red flags for fraud.
- SIU and the tort agent's obligation when fraud is suspected.  Claim report writing.
- The evaluation and regulation of personal injury claims.
- How to retain coverage assistants to help when a coverage problem is discovered.
- How to check coverage
- an expert.
- How to check the expert.
- Consult with a plaintiff's lawyer.
- Handles with personal injury defenders.
- The evaluation and regulation of the claim and . mediation and claims represent ntative.
It takes courage to fight insurance fraud
The Legislative Assemblies of the various states, the United States Congress, the National Association of Insurance Commissioners, the National Insurance Crime Bureau and Insurance
have finally decided that industry groups the war on insurance fraud is worth fighting.
Until the states, local police, district prosecutors, US prosecutors and prosecutors from the various states join the fight, it will be fought to a deadlock. The insurance industry cannot successfully fight insurance fraud alone.
Insurance industry sources estimate insurance fraud ranging from a minimum of $ 80,000,000,000 ($ 80 billion) per year to peaks of $ 300,000,000,000 ($ 300 billion) per year. Regardless of which, if any, estimate is correct, the amount of money that goes to insurance criminals is astounding and approaches no less than 3% to 10% of the premium collected.
Every other week Zalma's insurance fraud letter publishes lists over convictions. The largest volume of such convictions is for Medicare and Medicaid fraud. Basic convictions for property and victim fraud are rarely described except when the perpetrator admits or pleads guilty. Few go to trial. Those convicted are usually sentenced to shorter stays in prison or to domicile.
Insurance fraud is not a local problem. It is an impoverishment of the wealth of the whole country. The Attorney for the Department of Insurance in each state is the State Attorney General. A special unit could be set up in the Attorney General's office, financed with the money taken from the insurance industry to support the war on insurance fraud. This unit should be given a simple mandate:
Report and prosecute any insurance fraud that comes to the unit by the Fraud Division that has a chance of more than 50% success.
The unit should not concentrate its efforts on major insurance frauds. These can best be prosecuted by large fraud units that already exist in the district attorney's offices and in the offices of the U.S. Attorney General.
The state unit should concentrate on prosecuting everyday insurance fraud, opportunity fraud that takes 90% of money paid to fraud perpetrators, in the range of $ 5,000 to $ 50,000.
Individual cases should be prosecuted. When prosecutors file several charges against individual defendants, the case becomes a major measure that requires a lot of time to bring charges. Judges and juries do not want to be involved in a prosecution that takes months to prosecute.
If there are several points available, the prosecutor should only prosecute the one where the evidence of fraud is overwhelming. If the jury finds for the defendant, the prosecutor can prosecute the next point continuously until the statute of limitations expires.
If everyone available is prosecuted in one case, the prosecutor will insult the judge and the jury and the defendant will be pardoned by the jury. Overcharging charges is as bad as not prosecuting at all.
Teeth must be put in the posters that say "commit insurance fraud, go to jail." The insurance departments receive reports from insurance companies about thousands of potential fraudulent claims per month. They do not have the staff, the ability or the desire to investigate and prosecute every case brought to them. If only 5 percent of these claims are investigated and prosecuted, the deterrent effect will be enormous. The Ministry of Insurance should issue a press release on each arrest and
conviction. Newspapers should report daily that insurance offenders have been arrested and should be prosecuted or convicted and end up in jail. Imprisonment should be made mandatory and deprive local judges of the right to grant only probation and restitution to convicted criminals.
Punishment throughout the state must be consistent and true punishment. I have seen such an inconsistency where cases, after conviction, the criminals received sentences ranging from 24 hours to 24 years.
It is not enough that the state says that insurance companies must investigate and work to combat fraud. The state must also aggressively and vigorously fight insurance fraud.
Today, a person who commits an insurance fraud only needs to worry that an aggressive fraud investigation may delay, or reduce, the amount he can recover from his crime. Prosecution for the crime of insurance fraud is so minor, relative to the amount of fraud, that it does not exist. It really does not work as a deterrent. In connection with the establishment of a special prosecution unit for insurance fraud at the office of the Public Prosecutor's Office, legislators should adopt the following statutes:
From the entry into force of this statute, there is no tort of bad faith in this state.
Penal damages may not be awarded in that state.
Any insurer who inadvertently reports to the Fraud Division, Department of Insurance that it has rejected a claim for fraud may not be sued in any court in that state, for any grounds for damages.  This section is not intended to eliminate the right of an insured person to sue his insurer for breach of the insurance contract.
If legislators really want insurance companies to fight insurance fraud; whether legislators want to keep this important industry strong and viable; If legislators want to reduce the insurance premiums paid by their constituents, they will have to wage the war on insurance fraud in practice. As long as the violation of bad faith and the revelation of punitive damages hang over the insurance companies, the war will be a war where no one will win.
The stories I have fictionalized in this book were written to show how insurance fraud takes money out of the pockets of innocent and honest people who buy insurance. For every dollar taken by a fraud, an insurer must collect two dollars in premiums. Every person in the United States who does not commit fraud pays to support those who do. A minimum of $ 20.00 for every $ 100.00 each insured person pays in premiums ends up in the pockets of insurance offenders. If the stories in this book make the reader angry, write to your local District Attorney, State Prosecutor, Attorney General, or U.S. Attorney and let them know your anger.
If enough people complain, levels of prosecution will increase. Although each of the stories in this book are based on facts, the names, locations, and facts of the claims have been changed to protect the guilty. No resemblance to any person other than those specifically mentioned is intended and all similarities are purely random.
© 2021 – Barry Zalma
Barry Zalma, Esq., CFE, now limits his practice to the position of insurance consultant specializing in insurance coverage, handling of insurance claims, bad faith and insurance fraud almost equally for insurers and policyholders.
He also acts as an arbitrator or media for insurance-related disputes. He practiced law in California for more than 44 years as a lawyer for insurance coverage and claims management and more than 54 years in the insurance industry.
Subscribe to "Zalma on Insurance" at https://zalmaoninsurance.locals.com/subscribe and "Excellence in Claims Handling "at https://barryzalma.substack.com/welcome.
You can contact Mr. Zalma at https://www.zalma.com, https: //www,claimschool.com, email@example.com and firstname.lastname@example.org. Mr. Zalma is the first recipient of the first annual Claims Magazine / ACE Legend Award.
You can find the interesting podcast "Zalma On Insurance" at https://anchor.fm/barry-zalma; you can follow Zalma on Twitter at; you should watch Barry Zalma's videos on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; or videos at https://rumble.com/zalma. Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims–library/ The last two issues of ZIFL can be found at https://zalma.com/zalmas-insurance- fraud- letter-2 /