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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Insurance Expert May Not Testify to Speculative and Contains Unsupported Conclusions.
Posted on September 18, 2026 by Barry Zalma
See the full video at and at https://rumble.com/v7fmifw-expert-may-only-testify-to-what-experience-supports.html
In Michele A. Over, and The Estate Of Paul R. Over v. State Farm Mutual Automobile Insurance Company, and State Farm Fire And Casualty Company, Civil Action No. 23-cv-02243-PAB-STV, United States District Court, D. Colorado (September 14, 2026) Michele and Paul Over sued State Farm Fire and State Farm Auto over hail-damage and stolen-vehicle claims.
The operative dispute concerned State Farm Auto’s motion to exclude or limit opinions from plaintiffs’ insurance-industry expert, Aaron Castillo. Castillo.
Law
The proponent of expert testimony must establish by a preponderance of the evidence that an expert is qualified and that the opinions are helpful, sufficiently grounded, and reliably derived and applied. Experience-based opinions must explain how the...
150 Months in Prison for Tax Fraud
Post 4846
Posted on September 17, 2026 by Barry Zalma
See the full video at https://lnkd.in/g8rh3JBX and https://lnkd.in/gmkdy-9C, In United States Of America v. Thomas Addaquay, Nos. 25-10609, 25-10611, United States Court of Appeals, Eleventh Circuit (September 9, 2026) the Eleventh Circuit affirmed all challenged convictions, the 150-month aggregate sentence, and the challenged $4,123,474.55 restitution award.
FACTS
In United States Of America v. Thomas Addaquay, United States Of America v. Thomas Addaquay, Nos. 25-10609, 25-10611, United States Court of Appeals, Eleventh Circuit (September 9, 2026) the Eleventh Circuit affirmed all challenged convictions, the 150-month aggregate sentence, and the challenged $4,123,474.55 restitution award.
FACTS
Thomas Addaquay controlled United Consolidated Accounting and Business Services (UC), nominally a check-cashing business.
The government proved a three-stage tax-refund scheme that converted the resulting refund checks into usable funds through ...
Major Fraud Perpetrator Asserts Fifth Amendment Privilege to Avoid Prosecution
Post 5489
Posted on September 14, 2026 by Barry Zalma
Fraudster Refuses to Answer Questions About His Alleged Fraud
See the full video at https://lnkd.in/gvicAMDr and at https://lnkd.in/gvicAMDr
In Great American Insurance Co. v. Gemstone Property Management, LLC, et al., No. 23-cv-9100 (LJL), United States District Court, S.D. New York (September 8, 2026) Great American Insurance Company alleged that it was defrauded through a scheme in which Subin Associates, LLP recruited individuals to stage construction-site injuries, arranged unnecessary medical treatment and litigation funding, and pursued fraudulent personal-injury claims.
Luis Manuel Garcia Salcedo, resulted in a $6 million settlement. Non-party Jose Hernandez allegedly worked as an assistant manager at Subin, operated Hernandez Associates, and owned litigation-funding companies that shared office space with Subin and provided services to its clients.
After Great American ...
Accused of 17 Counts Of Fraud Attempts to Keep Out Evidence of Crimes
Post 4853
Posted on September 29, 2026 by Barry Zalma
Court Refuses to Grant Most Motions in Limine
In United States Of America v. Seth Allen Aikens, II, Criminal No. 22-119, United States District Court, W.D. Pennsylvania (September 23, 2026) Defendant Seth Allen Aikens II faces thirty federal counts. The indictment alleges that, from about June 2016 through March 2020, Aikens solicited start-up businesses seeking websites, applications, hosting, payment processing, and related services. The Government estimated aggregate losses of approximately $1.3 million involving about eight charged customers.
The Government also sought to introduce evidence involving three uncharged persons. Robert Polonsky allegedly paid about $10,000 for web development, hosting, and advertising services but did not receive the promised core deliverables. Brandon Canwright allegedly paid approximately $1,877 for a website and related services that were not delivered and received no ...
Accused of 17 Counts Of Fraud Attempts to Keep Out Evidence of Crimes
Post 4853
Posted on September 29, 2026 by Barry Zalma
Court Refuses to Grant Most Motions in Limine
In United States Of America v. Seth Allen Aikens, II, Criminal No. 22-119, United States District Court, W.D. Pennsylvania (September 23, 2026) Defendant Seth Allen Aikens II faces thirty federal counts. The indictment alleges that, from about June 2016 through March 2020, Aikens solicited start-up businesses seeking websites, applications, hosting, payment processing, and related services. The Government estimated aggregate losses of approximately $1.3 million involving about eight charged customers.
The Government also sought to introduce evidence involving three uncharged persons. Robert Polonsky allegedly paid about $10,000 for web development, hosting, and advertising services but did not receive the promised core deliverables. Brandon Canwright allegedly paid approximately $1,877 for a website and related services that were not delivered and received no ...
Inadequately Briefed Issues Defeats Appeal
Post 4852
Issues on Appeal Must be Adequately Briefed
Posted on September 25, 2026 by Barry Zalma
In Emy Ojekwe v. Connecticut Transit District Consortium, No. AC 47389, Court of Appeals of Connecticut (September 22, 2026) Emy Ojekwe alleged that he was injured on September 24, 2020, while leaving a bus operated by Connecticut Transit District Consortium, doing business as Greater Bridgeport Transit Authority.
According to his complaint, the wheelchair ramp began to rise before he had fully exited, causing his wheelchair to fall backward and allegedly injuring several parts of his body and damaging the wheelchair. The defendant denied negligence and alleged comparative negligence. After a two-day jury trial in November 2023, the jury returned a defense verdict.
The trial court denied Ojekwe’s motion to set aside the verdict and for a new trial, and he appealed.
LAW
A trial court’s refusal to set aside a verdict because of counsel’s improper remarks is reviewed for abuse of ...
