Programme overview
Introduction:
Insurance claims management and loss adjusting decide whether an insurer keeps its promise at a fair cost. Weak triage, loose coverage positions, stale case reserves and missed recoveries turn sound portfolios into claims leakage, complaints and avoidable arbitration. This Core Concept course equips insurer claims teams, adjusters and claims counsel to register and triage notified losses, test cover against the wording, quantify property and business interruption losses, set reserves, screen for fraud, negotiate settlements and pursue subrogation and reinsurance recoveries. Participants produce a Claims File Review and Settlement Recommendation for case losses.
Course Objectives:
- Run first notification of loss intake and triage claims by severity, complexity and settlement authority against written service standards
- Form and communicate a coverage position by testing each loss against insuring clauses, exclusions, conditions precedent and warranties
- Quantify property damage and business interruption losses using reinstatement, indemnity value, condition of average and gross profit methods
- Set and review case reserves and document reserve movements so claims finance and reinsurers can rely on the file
- Screen claims for fraud indicators, commission proportionate investigations and negotiate settlements with documented authority
- Pursue subrogation, contribution and reinsurance recoveries, handle disputes and complaints, and track claims KPIs and leakage
Target Audience:
- Claims supervisors who allocate files, approve payments within delegated authority and monitor service standards
- Loss adjusters who inspect damage, quantify losses and report to insurers on cover and quantum
- Claims counsel who advise on coverage disputes, declinatures, arbitration and recovery litigation
- Claims technical and quality reviewers who audit files for reserving accuracy and leakage
- Recovery and reinsurance claims coordinators who collect subrogation, salvage and treaty recoveries
- Complaints and customer resolution leads who investigate policyholder grievances about claim decisions
Course Outline:
Day 1: The Claims Function, Notification and Triage
- Claims Operating Model: In-House Handlers, Independent Adjusters and Delegated Authority Matrix
- Claims Service Standards Charter: Acknowledgement, Contact and Decision Timelines
- First Notification of Loss Intake Script and Minimum Data Set
- Severity and Complexity Triage Grid for Fast-Track, Standard and Major Losses
- Claims File Opening Checklist: Policy Verification, Diary Setting and Initial Reserve
Day 2: Coverage Analysis and Policy Response
- Coverage Test Sequence: Insured Party, Insured Property, Period and Operative Peril
- Exclusion Burden of Proof and Proximate Cause Reasoning on Loss Scenarios
- Conditions Precedent, Notification Breaches and Warranty Non-Compliance Consequences
- Reservation of Rights Letter and Declinature Letter Drafting Standards
- Multiple Policies, Contribution Between Insurers and Aggregation of Losses
Day 3: Loss Adjusting and Quantum for Property, Liability and Motor
- Property Damage Quantum: Reinstatement, Indemnity Value and Betterment Deductions
- Underinsurance Testing and Condition of Average Worked Calculation
- Business Interruption Adjustment: Gross Profit, Indemnity Period and Increased Cost of Working
- Liability Claims Handling: Legal Liability Assessment, Third-Party Contact and Litigation Monitoring
- Motor Own-Damage and Third-Party Claims: Repair Authorisation, Total Loss Valuation and Salvage
Day 4: Reserving, Fraud, Recoveries and Disputes
- Case Reserving Methods: Formula, Judgement and Reserve Adequacy Review
- Hard and Soft Fraud Red Flag Matrix and Referral to a Special Investigation Unit
- Subrogation Recovery Pathway: Rights Assessment, Notice to Third Party and Waiver Checks
- Reinsurance Claim Notification, Cash Call and Treaty Recovery Documentation Overview
- Complaint Root Cause Review, Mediation and Arbitration of Coverage Disputes
Day 5: Claims KPIs, Settlement and the Claims File Review
- Claims KPI Dashboard: Cycle Time, Reopen Rate, Reserve Accuracy and Recovery Yield
- Claims Leakage Audit Sampling and Root Cause Categories
- Settlement Negotiation Role Play: Ex-Gratia, Full and Final and Structured Payments
- Case Losses: Factory Fire, Warehouse Liability and Fleet Collision Files
- Claims File Review and Settlement Recommendation Drafting and Peer Challenge
Skills You Will Gain:
- Loss Notification Triage
- Coverage Position Analysis
- Loss Quantification
- Business Interruption Adjustment
- Case Reserve Setting
- Fraud Indicator Screening
- Subrogation and Recovery Management
- Claims Leakage Control
Why Attend This Course:
- Return with a Claims File Review and Settlement Recommendation built on realistic property, liability and motor case losses
- Defend coverage decisions, reserves and settlement amounts to supervisors, reinsurers and dispute panels with a documented rationale
- Recognise leakage points in open files, from late reserves to lost recovery rights, before they cost money
- Compare claims practice with adjusters, handlers and counsel from several insurers and lines of business
Conclusion:
Claims decisions show whether an insurer's wording, pricing and service promises hold in practice. The five days move from the claims function, notification and triage, through coverage analysis and loss quantification, to reserving, fraud screening, recoveries and dispute handling. The final day applies these methods to property, liability and motor case losses, tests settlement negotiation and closes with a Claims File Review and Settlement Recommendation that participants can apply to their own open files.