Legal Definitions - claims adjuster

Claims Adjuster

A claims adjuster is a professional employed by an insurance company, or an independent contractor working on their behalf, whose primary role is to investigate insurance claims. Their responsibility involves assessing the damages or losses incurred by a policyholder, determining the validity of the claim according to the terms of the insurance policy, and negotiating a fair settlement amount.

Here are some examples illustrating the role of a claims adjuster:

• Example 1: Residential Property Damage

  After a severe hailstorm damages the roof and siding of a homeowner's house, the homeowner files a claim with their insurance company. A claims adjuster is assigned to the case. The adjuster visits the property, inspects the damage, takes photographs, and obtains repair estimates from local contractors. They then review the homeowner's policy to ensure the damage is covered and calculates the appropriate payout, factoring in the deductible and depreciation.

  This example illustrates a claims adjuster's role in physically assessing damage, interpreting policy terms, and determining the financial compensation for property loss.

• Example 2: Automobile Accident Injury

  A driver is involved in a multi-car collision and sustains whiplash and other injuries, requiring medical treatment and time off work. They file a personal injury claim with the at-fault driver's insurance company. A claims adjuster for that company will review the police report, medical records, and witness statements. They might also interview the injured driver and the other parties involved to understand the circumstances of the accident and the extent of the injuries, ultimately proposing a settlement for medical bills, lost wages, and pain and suffering.

  Here, the claims adjuster evaluates personal injury claims, focusing on medical documentation, accident reports, and the impact on the claimant's life to arrive at a fair settlement offer.

• Example 3: Business Interruption Loss

  A small restaurant experiences a burst pipe that floods its kitchen, forcing it to close for two weeks for extensive repairs. The owner has business interruption insurance and files a claim for lost income during the closure. A claims adjuster specializing in commercial policies will examine the restaurant's financial records, such as sales figures and operating expenses from before and after the incident, to accurately calculate the lost profits and additional expenses incurred due to the interruption, ensuring the payout aligns with the policy's coverage.

  This scenario demonstrates a claims adjuster's function in assessing complex financial losses for businesses, requiring an understanding of accounting principles and specific commercial insurance coverages.