The Role of Ethics in the World of Insurance Claims
- October 12, 2022
- Posted by: April Hilbert
- Category: Adjuster Licensing Best Practices Claims Management eLearning
Ethics is a major consideration when deciding to pay or deny a claim as an insurance adjuster.
Is it ethical to deny an obviously compensable claim, or to pay a claim clearly not due?
Is it ethical to take a position on either payment or denial when an investigation is still incomplete?
The answers to these questions may well depend on which side of the fence you’re on. Yet an adjuster’s role is not to pay every claim, nor is it to deny every claim. It is an adjuster’s responsibility to have a solid understanding of the law, to investigate the facts of a particular case, and then provide the benefits, coverages, payments or protections that are due, and deny them when they are not.
In cases where the facts and law are unclear, or lead to conflicting positions, it is an adjuster’s responsibility to find a satisfactory resolution in compromise of disputed issues (i.e., settlement).
Opinions often differ, depending on the motivations of the interested parties. Adjusters must be guided by not only their own investigation and evaluation into the merits of the claim, but also their own moral or ethical compass. In the end, when caught between competing interests, one must consider the law in question, the requirements of the insurance policy, and remember the recommendations of the ancient Chinese philosopher Confucius who said, “Do not inflict on others what you yourself would not wish done to you.”
In the words spoken decades ago by one of our nation’s most respected carriers, “It is our job to pay what we owe, no more, no less…” Unfortunately, it is often the “no less” that some forget.
Adjusters should govern their actions and make decisions based on the best interests of their customers. These customers comprise not only their employer or client, the insurance carrier, but also the insured policyholder, and in some cases, even a third party claimant who is depending on the fair and honest treatment by a carrier responding to the liability of its insured.
The claims profession requires adjusters to use their knowledge and expertise for the benefit of their customers. Provided that coverage is in order, or liability is clear, an adjuster’s chief “customer” is the person who suffered the loss.
Unfortunately, the answers to many of the ethical dilemmas adjusters often face are not always easy to find, and the adjusting community is not alone in this challenge. While some organizations have published ethics rules, and others have developed ethics programs, even these groups have struggled with all the issues that must be considered in the development of such programs.
The challenges cast by the requirement to “act ethically” have consistently frustrated most occupations and professions at one time or another. The examples of Enron, WorldCom, and “Bernie” Madoff’s Ponzi schemes have become synonymous with ethical failure. These examples violated our society’s sense of trust. But the issue of ethics is much broader in scope than simply the public’s trust, or censuring or preventing illegal behavior while simultaneously encouraging proper behavior.
As a professional, one must not only guard against accidental or unintentional “unethical” behavior, one must also be aware of, and guard against, the underhanded. Handling a claim without the necessary level of competency is, in fact, a serious breach of one’s responsibility to the customer. Adjusting is a profession that can provide a lifetime of challenge, reward and financial stability; thus, it should remain a profession requiring the highest levels of commitment and diligence.
This is a large part of the reasoning behind requiring ethics courses be taken during each Continuing Education term for Insurance Adjusters. We must always be reminded of and given examples and perspectives we can apply when adjusting claims.
The Matter of Ethics course, provided by AE21 online, aims to provide a small yet important positive force for good in those who practice the world of claims. By taking this very thorough course your confidence and comfort will increase when making ethically challenging claims decisions.
This course is all about an adjuster’s responsibility for ethical behavior in claims handling. In this course, you will learn various definitions and perspectives on ethics, actions that constitute ethical behavior, and actions that do not. You will learn practical dilemmas that one may face throughout a claims career and the issues that should be considered when making decisions that guide your actions in dealing with those dilemmas.
When you complete this course, you will:
- Understand various perspectives governing behavior, what is considered proper ethical behavior, and some of the moral requirements of claim handling.
- Identify professional standards of conduct.
- Understand the requirements of good, and poor, claim handling as prohibited by the various Unfair Claims Practices Acts of Texas, Florida, North Carolina and others.
- Understand issues presented in trying to ethically balance the sometimes-diverging interests of policyholders, claimants, and insurance carriers.
You’ll gain all these objectives while working your way through our user-friendly and engaging online course. You can enroll in A Matter of Ethics at our eLearning platform HERE. If you already have an account with us, simply log in and select the course from the course catalog. If you do not already have an account, begin by creating an account and selecting your licensing state. You will then have access to our full course catalog for your state of licensure. For more assistance with creating an account and purchasing courses, please watch THIS VIDEO.
For additional Ethics CE credits, you may also want to check out our CE course The Ethical Practices of an Adjuster.