CSR SPR Criteria - Timely Investigation

mcvonbraun's version from 2015-06-17 20:06

Section 1

Question Answer
What should the file handler do in regards to coverage?Recognize and verify applicable coverage timely.
Coverage issues and vehicle condition codes should be resolved prior to what?Extending coverage or authorizing payments
What is required for investigations beyond 30 days?Adequate documentation and agressive attempts to secure the needed information (critical)
What needs to be documented indicating how it was resolved? All coverage conditions and/or vehicle condition codes (critical)
What should the handler do if there are coverage issues not automatically established on the claim (ie permissive use)?Add the coverage issue to the claim as soon as it is identified and handle appropriately. (critical)
What are the questions the reviewer of coverage should consider? 1. Did the file handler evaluate the policy contract, coverage conditions, vehicle condition codes, policy issues and state regulations completely?
2. Did the file handler resolve all coverage issues prior to advising of good coverage?
3. Was an ROR used where appropriate?
4. Permissive use addressed?
5. Was business/government/rideshare use addressed and documented in notes? This is for collision losses only, does not include comp or parked and unoccupied losses. If the owner (resident relatives only) has already verified no business, government use it's not necessary to verify with the driver. Business/government use documentation generated by call driver is sufficient documentation for Ridesharing addressed.(Critical)
6. Were vehicle/motorcycle customizations investigated properly?
7. On motorcycle claims, was helmet coverage addressed and documented?
8. Did the file handler obtain evidence to resolve the coverage issue?
9. Was there appropriate RLA, Manager, CHO, SIU and Underwriting involvement?
10. Did we contact a previous insurer for possible duplicate coverage or other facts of coverage?
11. Is there suppporting documentation (i.e. Underwriting referrals) to reflect any policy changes?
12. Should the file have been transferred to another level? If so, the file must be properly assigned within 24 hours of known exposure. (Critical)
13. Did the file handler make a referral to Underwriting upon discovery of pertinent information that may affect the policy? (Critical)

Section 2

Question Answer
What is the SPR auditor reviewing?The quality of the medical investigation
What needs to be documented in relation to passengers?Confirmation of whether there were or weren't passengers in the vehicle
What is the file handler required to make as a reasonable attempt? Reasonable attempt to contact all interested parties to verify first and third party injuries (critical)
What constitutes a reasonable attempt?This is determined by the nature of the claim, the information available, and the reviewer's judgment. If this is not done, the category should be rated N/S.
Who can rule out injuries for a passenger (except for minor children)? The driver of the vehicle, in most cases. If the extent of the damages or nature of the loss is significant, direct contact with passengers to rule out injuries should be made.
Who must rule out injuries for a minor child?The parents/guardians of the minor child must rule injuries for the minor.
What must the examiner do in addition to ruling out injuries?They must confirm occupants were over 18 and appropriate documentation must be present.(critical - to rule out injuries to all interested parties)

Section 3

Question Answer
What overall is this subcategory measuring?Whether the file handler confirmed the facts of the loss promptly and verified liability to support the position taken on negligence.
How long does the file handler have to verify liability? 30 days (critical)
For the long form FNOL, what is the file handler required to do?The file handler is required to make a reasonable attempt to contact all interested parties to verify third party PD exposures (critical). If the insured strikes a non-vehicle object (pole, fence, etc) and indicates there is no damage to that object, the file handler is not required to attempt contact to confirm unless other sources indicate further investigation is needed. Notes should be documented confirming there was no damage (critical).
What constitutes a reasonable attempt? This is determined by the nature of the claim, the information available, and the reviewer's judgment.
What is necessary if no contact attempts are made by the file handler? Appropriate notes documentation must be present. If this is not done, the overall file should be rated N/S.
What are the questions that should be addressed under the liability section?1. Were reasonable attempts made to verify all property damage exposures? (critical)
2. For long form FNOL, was the police report needed? Was it ordered timely?
3. Did the file handler secure all necessary information prior to making a liability decision (critical).
4. Should the file have been assigned to another level? If so, the file must be properly assigned within 24 hours of the known exposure (critical)
5. Was an SIU referral needed and not sent?
On a double GEICO claim that is word versus word in a pure comparative state, how should the file handler treat the customer on the cross file?They are to treat the customer on the cross file the same as they would an adverse carrier or claimant. From a customer service perspective, some regions may key liability at 0%.
If liability is keyed at 0% on a double GEICO, word versus word, pure comparative claim, the following must apply1. The file must be documented by a supervisor
2. Key 0% negligence for the insured
3. Assess the insured's deductible at 50% (based on assumption of arbitration decision of 50%)
4. Transfer 50% of the insured's deductible to the crossfile.
Double GEICO's that are word versus word in a pure comparative state are the only claims where this procedure is acceptable. All other claims must have % negligence, liability decision, and payments matching regarding liability assessment (critical).
What are the investigation critical errors?1. Coverage not investigated or properly reserved
2. Proper coverage not recognized/applied (ex: COL but UPD applies)
3. Helmet coverage not addressed and documented separately
4. Failure to send underwriting referrals
5. Failure to rule out passengers (long form FNOL)
6. Failure to verify injury exposures
7. Failure/delayed transfer of claim
8. Delayed liability investigations (long form FNOL)
9. Premature liability decision (long form FNOL)
10. Was new information discovered to warrant further investigation and file handling
11. Failure to rule out property damage`
What is the investigation category error?May include: incorrect liability decision when it involves a % negligence claim.