HOW TO CREATE AN EXCELLENCE IN CLAIMS HANDLING PROGRAM
See the full video at https://rumble.com/v70wb2i-the-zalma-philosophy-of-claims-handling-part-6.html and at https://youtu.be/tL5nDKPEs40 and at https://zalma.com/blog plus more than 5200 posts.
Post 5217
This is a change from my normal blog postings. It is my attempt. in more than one post, to explain the need for professional claims representatives who comply with the basic custom and practice of the insurance industry.
An Excellence in Claims Handling program begins with a statement in the insurer’s claims manual or statement of professionalism that it is dedicated to providing excellence in claims handling to every insured who presents a claim.
The excellence in claims handling program should include, at a minimum:
A series of lectures supported by text materials explaining:
A definition of insurance.
How to read and understand an insurance policy.
How to interview an insured, witness, or claimant.
How to assist an insured in the insured’s obligation to prove a claim.
How to repair or replace damaged real or personal property.
How to repair or replace damaged vehicles.
How to identify causes of loss.
How to recognize the red flags of fraud.
The duty of the claims person who suspects attempted fraud.
How to negotiate with an insured, claimant, public adjuster or lawyer to resolve a claim.
How to recognize when retaining counsel to represent the insurer is necessary.
How to retain counsel to represent the insured.
How to read and understand the contract that is the basis of every adjustment, including but not limited to the formation of the insurance policy and the rules of contract interpretation.
Tort Law: Including Negligence, Strict Liability in Tort, and Intentional Torts.
Contract law including:
the insurance contract,
the commercial or residential lease agreement,
the bill of lading, nonwaiver agreements,
proofs of loss,
releases of claims,
non-waiver agreements,
other claims related contracts or documents,
The duties and obligations of the insured in a personal injury claim,
The duties and obligations of the insurer in a personal injury claim,
The duties and obligations of the insured in a first party property claim,
The duties and obligations of the insurer in a first party property claim, and
The Fair Claims Practices Act and the Regulations that enforce it.
The Thorough Investigation, Including:
Basic investigation of an auto accident claim.
Investigation of a construction defect claim.
Investigation of a first party property claim.
The Red Flags of Fraud.
The SIU and the obligation of the claims representative when fraud is suspected.
Claims Report Writing.
The evaluation and settlement of the personal injury claim.
Evaluation and investigation of a Marine or Inland Marine claims.
Evaluation and investigation of the property claim for fire, lightning, windstorm, hail, theft or burglary.
How to retain coverage counsel to aid when a coverage issue is detected.
How to control coverage counsel to limit counsel to the opinions needed.
Instruction, by Lecture, Documents & Webinars
Dealing with a plaintiff’s lawyer.
Dealing with personal injury defense counsel.
The evaluation and settlement of the property damage claim.
The Appraisal process.
Arbitration and mediation and the claims representative.
Any other topics particular to the insurer.
Claims handling without excellence is both dangerous and expensive. Insurers must develop a professional claims staff and provide excellence in claims handling because by doing so they will profit more than if they keep an inadequate and unprofessional claims staff.
The training lectures must be supplemented by meetings between knowledgeable and experienced supervisors and claims staff on a regular basis to reinforce the information learned in the lectures.
To guarantee that the training and requirement for excellence in claims handling is effective the insurer must also institute a regular program of auditing claims files to establish compliance with the requirement to deal fairly and in good faith to the insured.
The insurer’s management must support the training and repeat it regularly because people have short term memory loss and need to reinforce what they have learned and what is required of them when dealing with an insurance claim. The professional claims handler never sees the identical claim every time. Claims, factual background, and the people involved are invariably different and the professional claims handler must be capable of adapting to the people and facts involved.
The insurer’s management must, therefore, be committed to audit claims files to determine whether the training has taken and is being applied to each claim. It is imperative that claims management determines whether there is a need to refresh the memory of the claims personnel and add new information and claims processes.
There is no quick and easy solution. Excellence in claims handling training takes time; learning takes longer and must be repeated and modified to changed situations and new and modified appellate decisions changing the interpretation of a policy wording.
If the insurer does not have personnel with the ability to train its staff it should use outside vendors who can do so effectively. Many such sources are available from colleges, universities, professional associations, independent claims adjuster firms, independent counsel, insurance related publications, insurance related podcasts, and continuing education providers.
Part Seven of The Zalma Philosophy of Claims Handling will deal with the creation of an Excellence in Claims Handling Program.
Now available on Amazon.com my newest book started from these blogs “Unlocking the Art & Science of Claims Handling Mastery”
(c) 2025 Barry Zalma & ClaimSchool, Inc.
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Convicted Criminal Seeks to Compel Receiver to Protect his Assets
Post number 5291
See the video at and at and at https://www.zalma.com/blog plus more than 5250 posts.
The Work of a Court Appointed Receiver is Constitutionally Protected
In Simon Semaan et al. v. Robert P. Mosier et al., G064385, California Court of Appeals, Fourth District, Third Division (February 6, 2026) the Court of Appeals applied the California anti-SLAPP statute which protects defendants from meritless lawsuits arising from constitutionally protected activities, including those performed in official capacities. The court also considered the doctrine of quasi-judicial immunity, which shields court-appointed receivers from liability for discretionary acts performed within their official duties.
Facts
In September 2021, the State of California filed felony charges against Simon Semaan, alleging violations of Insurance Code section 11760(a) for making...
When There are Two Different Other Insurance Clauses They Eliminate Each Other and Both Insurers Owe Indemnity Equally
Post number 5289
In Great West Casualty Co. v. Nationwide Agribusiness Insurance Co., and Conserv FS, Inc., and Timothy A. Brennan, as Administrator of the Estate of Pat- rick J. Brennan, deceased, Nos. 24-1258, 24-1259, United States Court of Appeals, Seventh Circuit (February 11, 2026) the USCA was required to resolve a dispute that arose when a tractor-trailer operated by Robert D. Fisher (agent of Deerpass Farms Trucking, LLC-II) was involved in a side-impact collision with an SUV driven by Patrick J. Brennan, resulting in Brennan’s death.
Facts
Deerpass Trucking, an interstate motor carrier, leased the tractor from Deerpass Farms Services, LLC, and hauled cargo for Conserv FS, Inc. under a trailer interchange agreement. The tractor was insured by Great West Casualty Company with a $1 million policy limit, while the trailer was insured by Nationwide Agribusiness Insurance Company with a $2 million ...
Opiod Producer Seeks Indemnity from CGL Insurers
Post number 5288
Read the full article at https://lnkd.in/guNhStN2, see the full video at https://lnkd.in/gYqkk-n3 and at https://lnkd.in/g8U3ehuc, and at https://zalma.com/blog plus more than 5250 posts.
Insurers Exclude Damages Due to Insured’s Products
In Matthew Dundon, As The Trustee Of The Endo General Unsecured Creditors’ Trust v. ACE Property And Casualty Insurance Company, et al., Civil Action No. 24-4221, United States District Court, E.D. Pennsylvania (February 10, 2026) Matthew Dundon, trustee of the Endo General Unsecured Creditors’ Trust, sued multiple commercial general liability (CGL) insurers for coverage of opioid-related litigation involving Endo International PLC a pharmaceutical manufacturer.
KEY FACTS
Beginning as early as 2014, thousands of opioid suits were filed by governments, third parties, and individuals alleging harms tied to opioid manufacturing and marketing.
Bankruptcy & Settlements
Endo filed Chapter 11 in August 2022; before bankruptcy it ...
Passover for Americans
Posted on February 19, 2026 by Barry Zalma
“The Passover Seder For Americans”
For more than 3,000 years Jewish fathers have told the story of the Exodus of the enslaved Jews from Egypt. Telling the story has been required of all Jewish fathers. Americans, who have lived in North America for more than 300 years have become Americans and many have lost the ability to read, write and understand the Hebrew language in which the story of Passover was first told in the Torah. Passover is one of the many holidays Jewish People celebrate to help them remember the importance of G_d in their lives. We see the animals, the oceans, the rivers, the mountains, the rain, sun, the planets, the stars, and the people and wonder how did all these wonderful things come into being. Jews believe the force we call G_d created the entire universe and everything in it. Jews feel G_d is all seeing and knowing and although we can’t see Him, He is everywhere and in everyone.We understand...
Passover for Americans
Posted on February 19, 2026 by Barry Zalma
Read the full article at https://www.linkedin.com/pulse/passover-americans-barry-zalma-esq-cfe-5vgkc.
“The Passover Seder For Americans”
For more than 3,000 years Jewish fathers have told the story of the Exodus of the enslaved Jews from Egypt. Telling the story has been required of all Jewish fathers. Americans, who have lived in North America for more than 300 years have become Americans and many have lostthe ability to read, write and understand the Hebrew language in which the story of Passover was first told in the Torah.
Passover is one of the many holidays Jewish People celebrate to help them remember the importance of G_d in their lives. We see the animals, the oceans, the rivers, the mountains, the rain, sun, the planets, the stars, and the people and ...
You Get What You Pay For – Less Coverage Means Lower Premium
Post number 5275
Posted on January 30, 2026 by Barry Zalma
See the video at and at
When Experts for Both Sides Agree That Two Causes Concur to Cause a Wall to Collapse Exclusion Applies
In Lido Hospitality, Inc. v. AIX Specialty Insurance Company, No. 1-24-1465, 2026 IL App (1st) 241465-U, Court of Appeals of Illinois (January 27, 2026) resolved the effect of an anti-concurrent cause exclusion to a loss with more than one cause.
Facts and Background
Lido Hospitality, Inc. operates the Lido Motel in Franklin Park, Illinois. In November 2020, a windstorm caused one of the motel’s brick veneer walls to collapse. At the time, Lido was insured under a policy issued by AIX Specialty Insurance Company which provided coverage for windstorm damage. However, the policy contained an exclusion for any loss or damage directly or indirectly resulting from ...
