Latest / The Art of Adjusting® Podcast / Episode #101: Assume Less And Investigate Better

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Episode #101: Assume Less And Investigate Better · The Art of Adjusting® Podcast

• 0:06
  William Auten: Hello, I'm Bill Auten of Auten Claims Management.
• 0:09
  Chantal Roberts: I'm Chantal Roberts of CMR Consulting, and welcome to the Art of Adjusting podcast.
• 0:14
  William Auten: Today we're going to talk about life as an insurance adjuster from the perspective of property, auto, liability, or workers' compensation adjusters.
• 0:22
  William Auten: Our goal is to bring interesting topics in the world of claims adjusting to people who are working as an adjuster now and to people who are considering a career as a claims adjuster.
• 0:31
  William Auten: Hey Chantal, how are you?
• 0:32
  Chantal Roberts: Doing well, thanks.
• 0:33
  Chantal Roberts: How are you?
• 0:34
  William Auten: Good.
• 0:34
  William Auten: Uh we're all back home now.
• 0:36
  William Auten: And uh and you are too, I see.
• 0:38
  Chantal Roberts: Yeah, you know, it it happens in the office this time instead of the uh dungeon.
• 0:45
  Chantal Roberts: Yeah.
• 0:46
  William Auten: That was so much fun.
• 0:47
  William Auten: It was.
• 0:48
  William Auten: We had a blast out there in uh in Kansas City, and um we uh stayed in Missouri uh for the first few days and had a blast there as well.
• 0:58
  William Auten: And uh yeah, looking forward to coming back at some point.
• 1:01
  William Auten: It's um a neat place to visit.
• 1:03
  William Auten: If anybody has ever been to Weston, uh Missouri, uh very cool.
• 1:08
  William Auten: It's a tiny little town.
• 1:10
  William Auten: I felt like we were one of about a dozen people that were staying there.
• 1:14
  William Auten: Um, so we had pretty much the whole place to ourselves.
• 1:19
  William Auten: It was it was really cool.
• 1:20
  Speaker 2: Yeah.
• 1:21
  William Auten: Um but today we are talking about the most dangerous word in claims.
• 1:28
  William Auten: And what do you think that is?
• 1:30
  Chantal Roberts: Denied?
• 1:32
  William Auten: Nope.
• 1:33
  Chantal Roberts: Because you know, a lot of people get upset when their claims are denied.
• 1:37
  William Auten: They they do, but that's not danger, that's just the way the cookie crumbles sometimes.
• 1:42
  William Auten: Uh the danger comes when you assume.
• 1:46
  Chantal Roberts: Ah, assume, yes, yes, absolutely.
• 1:49
  William Auten: So I've been told I have to say, when you assume, you make an ass out of you and me.
• 1:56
  Chantal Roberts: Absolutely.
• 1:56
  Chantal Roberts: I mean, you know, that is a great way to remember how to spell it, too.
• 2:00
  Chantal Roberts: But you but you can make yourself uh maybe a little donkey butt or a whole donkey, I don't know, um, by by assuming things, and which is something that an adjuster should never do.
• 2:16
  William Auten: No, and it's easy to do.
• 2:18
  Chantal Roberts: Uh it is very easy.
• 2:20
  Chantal Roberts: Uh I am talking, I'm facilitating right now CPCU 530, which is the legal environment of that's my favorite one, you know, and and one of the things that some of the the veteran insurance professionals have issues with is the same thing that I have an issue with, is we read the question and we say, Well, all of these answers could be it.
• 2:51
  Chantal Roberts: And I have to tell them, turn off your mind, you know, approach it with what meditation calls a beginner's mind because you can't assume things.
• 3:07
  William Auten: Yes, it um, and when you do, uh, it sets up the confirmation bias that I always talk about, uh, where you get it in your it's in your head one way, and it's so hard to change your opinion on it.
• 3:22
  William Auten: Right.
• 3:23
  William Auten: And you could be wrong, you know.
• 3:25
  Chantal Roberts: And as you say, it's very dangerous, it's what leads to lawsuits, for sure, is when the adjuster like digs in their heels and says, No, this is the way it's gonna be.
• 3:37
  William Auten: I we see so many loss notices come in that are crafted by an agent who you know, if anybody's gonna be biased, it's gonna be the agent.
• 3:48
  William Auten: They're going to listen to their insured, they're gonna take their insured's side.
• 3:53
  William Auten: We as adjusters can't take sides.
• 3:56
  William Auten: We have to we have to look at all of the facts and we have to look at both sides, and we have to weigh which one uh has more um teeth to it, you know, which which version of the truth, because there's going to be different versions, which version is uh more likely to be the correct one.
• 4:18
  Speaker 2: Yes.
• 4:18
  William Auten: And if you don't approach it like that, you'll read what the biased agent says in the loss notice about whose fault it was or what happened, whatever, and that will burn into your brain, and everything that you do will be an attempt to confirm that.
• 4:38
  William Auten: Yes, that that pre-conceived notion of what happened.
• 4:42
  William Auten: Yes, yeah, and and that could that that will make more work for you, more unnecessary work, because you'll be led down stupid rabbit holes that have nothing to do with the issue at hand.
• 4:53
  William Auten: And we see that a lot here.
• 4:56
  Chantal Roberts: Yeah.
• 4:57
  Chantal Roberts: So how uh I guess what is an assumption that you see adjusters make repeatedly that absolutely drive you crazy?
• 5:07
  William Auten: Um, I think the first one is that um every claim is fraud.
• 5:13
  William Auten: Um, I I actually see that uh I hear that from adjusters where they'll say, you know, it's they're all fraud.
• 5:22
  William Auten: Well, maybe not, you know.
• 5:24
  William Auten: Sometimes sometimes somebody really makes a mistake and uh somebody really gets hurt because of that mistake, and it's it's not fraud, and it's actually somebody's fault.
• 5:36
  William Auten: Right.
• 5:36
  William Auten: That exists, you know.
• 5:38
  William Auten: People make mistakes and uh they are negligent and they do cause injuries and damages to others.
• 5:44
  William Auten: Um it doesn't necessarily make them a bad person, they just made a mistake.
• 5:51
  William Auten: Right.
• 5:51
  William Auten: Uh sometimes bad people make mistakes too, and they have a track record of doing that, and that's a different story, but um anyway, back to um uh assumptions here.
• 6:05
  Chantal Roberts: Yeah, how does it how did assumptions, I guess, become some kind of uh a fact, I suppose?
• 6:12
  Chantal Roberts: Because I think overall, to bring it in worldwide, we have kind of forgotten the difference between an opinion and an assumption and a fact.
• 6:24
  William Auten: Yeah.
• 6:25
  William Auten: It's very easy to be persuaded by a well-written letter or a well-produced video or commentary.
• 6:33
  William Auten: Uh, look at um, well, look at just your your algorithm these days on social media, and somebody will present something in a way that sounds very convincing, even though it's total BS.
• 6:47
  William Auten: Right.
• 6:47
  William Auten: I mean, how often do you see that?
• 6:50
  William Auten: There's a phrase, uh it had I saw it on the internet, so it must be true.
• 6:54
  William Auten: Exactly.
• 6:55
  William Auten: And and people say that jokingly because it's the opposite is the case.
• 7:00
  Chantal Roberts: Exactly.
• 7:01
  Chantal Roberts: Yeah.
• 7:01
  Chantal Roberts: Uh I used in the book, uh, The Art of Adjusting My Book, uh, thus the name of the podcast.
• 7:08
  Chantal Roberts: Uh the idea of explaining the difference between like an assumption, an opinion, and fact is imagine that there are two pundits on a news, CNN, Fox, whatever.
• 7:23
  Chantal Roberts: And one of them is saying, No, you know, you need water to live.
• 7:29
  Chantal Roberts: You know, every human needs water to live.
• 7:32
  Chantal Roberts: That is an established fact.
• 7:33
  Chantal Roberts: And then I come up and I go, No, no, no, no, no.
• 7:36
  Chantal Roberts: I need Diet Coke to live.
• 7:38
  Chantal Roberts: I don't need water to live.
• 7:40
  Chantal Roberts: Well, that is my opinion that has become my fact.
• 7:43
  Chantal Roberts: There's no scientific proof that Diet Coke is going to keep me alive.
• 7:47
  Chantal Roberts: I need some kind of hydration, to be sure.
• 7:51
  Chantal Roberts: And humans can't live long, uh, what, three days without water or whatever.
• 7:57
  Chantal Roberts: Um, so yes, we we definitely need some kind of hydration, but that is an assumption that I need Diet Coke versus what is a fact.
• 8:07
  Chantal Roberts: I need hydration to live as a human being.
• 8:10
  William Auten: Right.
• 8:10
  William Auten: Um, facts are facts, opinions are opinions.
• 8:14
  William Auten: And I I keep going back to the lost notice because that's that's where the root of of this evil can really take place is the description of what happened in the lost notice.
• 8:28
  William Auten: And a lot of times it will be um, you know, claimant alleges they slipped on the stairs, but we think it happened uh somewhere else.
• 8:37
  William Auten: Oh, really?
• 8:37
  William Auten: That's a bold thing to say.
• 8:39
  Chantal Roberts: Yeah, that is an assumption, that's an opinion because again, facts or your opinion can be based on facts, to be sure.
• 8:50
  Chantal Roberts: And I think we're gonna talk about that a little bit later about the progression of everything.
• 8:55
  Chantal Roberts: But yeah, it definitely starts with facts.
• 8:59
  Chantal Roberts: Because speaking of your loss notice, I had written articles previously where I'm urging adjusters not to necessarily pay so much attention to what is written in the first loss notice because the insured may use the wrong word.
• 9:17
  Chantal Roberts: My basement was flooded.
• 9:19
  William Auten: Right.
• 9:20
  Chantal Roberts: Well, it wasn't flooded, the sump pump stopped working, or we had a toilet overflow or a backup or something like that, but they don't know those words.
• 9:30
  William Auten: Well, I mean, to say that it wasn't flooded is technically not true.
• 9:35
  William Auten: A flood is, you know, under the Webster's definition, probably is a flood, but under the definition in your policy, no.
• 9:44
  William Auten: Right.
• 9:45
  William Auten: Um, so uh the the the language of insurance is quite different.
• 9:52
  William Auten: Um and and you need to have awareness about that as an adjuster too, so that you can recognize that okay, this was written by some by by an insured who's never read their policy in their life.
• 10:05
  William Auten: I'm not going to just assume they're talking about an excluded flood event in the policy.
• 10:12
  William Auten: I'm going to use my gray matter and think, hmm, maybe, just maybe it was a burst pipe, or maybe it was uh some pump failure, and they have you know 5,000 in coverage for that or whatever.
• 10:25
  William Auten: Um uh that's where uh and and there are people in this profession that have different experiences and backgrounds and different job roles.
• 10:39
  William Auten: And the the job role of an agent versus a claims adjuster uh at some time in some cases are so far apart to be frustrating because you will have an agent who won't have that self-awareness and will see the word flood.
• 10:56
  William Auten: And you know, three claims ago, they saw flood was excluded.
• 11:00
  William Auten: So maybe they don't report it because they know they think it's not covered.
• 11:05
  William Auten: Right.
• 11:06
  William Auten: I don't ask me why an agent would do that, but they do that.
• 11:11
  William Auten: Um if you're an agent that does that, please stop.
• 11:14
  William Auten: Just report it to the carrier, let them let them sort it out.
• 11:18
  Chantal Roberts: Um you're opening yourself up, but anyway, yes.
• 11:21
  Chantal Roberts: So let's let's talk about uh copying.
• 11:26
  Chantal Roberts: Um I see a lot of this uh assumption when assumptions become facts, when an adjuster maybe inherits a file and assumes the prior investigation.
• 11:40
  Chantal Roberts: And instead of going back and reading all of the notes, looking at all of the emails, all of the correspondence, and making their own decision, they rely on what the prior adjuster did, which could, as we talked about, be an assumption.
• 12:02
  Chantal Roberts: It could be a wrong assumption.
• 12:04
  Chantal Roberts: And I know everybody thinks, I don't got time for that.
• 12:07
  Chantal Roberts: You're absolutely right, you don't have time for it.
• 12:10
  Chantal Roberts: But again, that's what you need to do.
• 12:12
  Chantal Roberts: It is it is part and parcel of taking over a file because now you are the owner.
• 12:19
  Chantal Roberts: And if it gets to lawsuit, you're gonna be the one on the stand.
• 12:26
  William Auten: Yeah, and and having to explain um that you just made blanket assumptions to um you know, to a judge or a jury or uh an interrogating attorney uh isn't fun.
• 12:42
  Chantal Roberts: So how important are words like allege, reported, according to, and we confirmed by for adjusters?
• 12:52
  William Auten: Well um I think it's important to use those qualifiers when when you when you're not sure of the facts yet.
• 13:02
  William Auten: Right.
• 13:03
  William Auten: Um if uh if someone says that they were injured and you have verified where, when, and how, I would say use alleged.
• 13:14
  William Auten: Um or something like that.
• 13:19
  William Auten: Uh and I wouldn't I I don't think I would um stop using that until you have a very, very solid uh you have very, very solid proof that it happened the way it was said to have happened.
• 13:36
  William Auten: Um and that means that you have an insured who's maybe given you a statement and and said, I did this, I made this mistake, I apologize because I made this mistake.
• 13:49
  William Auten: They got hurt because I made this mistake.
• 13:52
  William Auten: This was 100% my fault.
• 13:54
  William Auten: If if you really don't have that level of confidence, I'd say stick with alleged.
• 14:01
  Chantal Roberts: You know, that's so funny because even though the insured may say it's 100% my fault, again, I sit there and go, they're not really insurance professionals, they may not know uh that the thing is open and obvious.
• 14:17
  Chantal Roberts: I was teaching my students about open and obvious and uh yesterday and with liability claims uh because their theory is well, if there's a lip in a sidewalk or something and I trip and fall, it's automatically the owner's fault.
• 14:36
  Chantal Roberts: And I'm like, well, no, not.
• 14:38
  Chantal Roberts: I mean, why did you did you see it?
• 14:40
  Chantal Roberts: Yes, right.
• 14:41
  Chantal Roberts: Well, then why is it my fault?
• 14:43
  Chantal Roberts: It's open and obvious.
• 14:44
  Chantal Roberts: Why did why did you trip?
• 14:46
  Chantal Roberts: Oh, you were looking at your phone.
• 14:47
  Chantal Roberts: That's not my fault.
• 14:49
  Chantal Roberts: So even if the insured goes, yep, my fault, blah, blah, blah.
• 14:53
  Chantal Roberts: I happen to use instead of alleged, I use alleged more in a legal sense, me personally.
• 14:59
  Chantal Roberts: This is me personally.
• 15:00
  Chantal Roberts: Uh, I use state or stated in my in claim notes.
• 15:06
  Chantal Roberts: I would say the insured stated, blah, blah, blah, the insured states, whatever.
• 15:12
  William Auten: Right.
• 15:13
  Chantal Roberts: That's just me though.
• 15:14
  Chantal Roberts: I mean, what you said is is absolutely correct.
• 15:17
  William Auten: Well, and um, to piggyback on what you're saying here, when a policy holder admits to fault 100%, they just gush that it was their fault, um, which doesn't happen a lot.
• 15:30
  William Auten: But a lot.
• 15:31
  William Auten: It it does happen.
• 15:33
  William Auten: Um, they may not understand that they were given a set of circumstances that were kind of out of their control.
• 15:41
  William Auten: And yeah, if they didn't do that one thing, the other thing wouldn't have happened.
• 15:46
  William Auten: But maybe they were given a piece of equipment that was poorly designed and dangerous, inherently dangerous, or maybe they had didn't have the proper training, or um, any number of other factors that that could be said to reduce their culpability, um, meaning that they they feel like they're 100% at fault, but really there's some other parties involved here, and we have to get them involved too, because they share in some of this um liability.
• 16:20
  Chantal Roberts: And I think this is showing how an assumption could turn into a fact, right?
• 16:26
  Chantal Roberts: Because the insured assumes that he's at fault, so he feels that that's a fact, whereas we as adjusters can't assume that.
• 16:35
  Chantal Roberts: As you said, we have to look at all the we have to look at all the facts or other options, right?
• 16:43
  William Auten: And and this is not to say that whenever somebody admits 100% fault, that there's always some other mitigating factor.
• 16:52
  William Auten: There's not it, it's that's not always the case.
• 16:54
  William Auten: Um, you know, sometimes somebody just makes a really bad mistake on their own, and and that causes an incident.
• 17:04
  William Auten: So that that is uh I mean, car accidents are a perfect example because you run a red light or you run a stop sign and you cause an accident, there's not a whole lot of other people to blame.
• 17:18
  William Auten: Um, in most cases, you know, maybe there's visibility factors, maybe there's speed issues, who knows?
• 17:25
  William Auten: But um anyway.
• 17:27
  Chantal Roberts: So, Bill, again, I always love to do this with my CPCU 530 class.
• 17:34
  Chantal Roberts: I um again gave them the left-hand turn issue.
• 17:38
  Chantal Roberts: And I had looked up uh the Kansas rules of the road to show them.
• 17:44
  Chantal Roberts: I'm like, look, if you have control of the intersection and you've got a left-hand turn, just because you're going straight doesn't mean you're, you know, the other person's at fault.
• 17:52
  Chantal Roberts: Anyway, just I'm gonna get off my high horse now.
• 17:55
  Chantal Roberts: We had a whole episode about you know, rules of the road, go look it up.
• 18:00
  Chantal Roberts: It's it's one of my pet peeves.
• 18:02
  Chantal Roberts: Just because you're making a left-hand turn does not mean you're at fault.
• 18:05
  William Auten: Okay, yeah, got that out of your system.
• 18:10
  Chantal Roberts: I did, I got it out of your system.
• 18:11
  Chantal Roberts: For now, yeah, thank you.
• 18:12
  Chantal Roberts: Sorry about that.
• 18:13
  William Auten: If you ever want to talk about left hand turns with me, you just let me know.
• 18:16
  Chantal Roberts: Okay, I'll do it.
• 18:18
  William Auten: Hey, um, as an aside, we have a new listener.
• 18:21
  Chantal Roberts: Oh, we do.
• 18:22
  Chantal Roberts: Hi, new listener.
• 18:24
  William Auten: Yes.
• 18:24
  William Auten: Um, this listener um happens to be uh uh very close to me and my family.
• 18:31
  William Auten: And um he believes, I think that he thinks that this um podcast was named after him.
• 18:37
  William Auten: Uh his name is Art.
• 18:39
  Chantal Roberts: Oh it totally was Art.
• 18:45
  William Auten: He uh he has been commenting, sending me text messages on every episode.
• 18:51
  William Auten: He is listening to episode after episode.
• 18:55
  Chantal Roberts: Oh, he's binge listening.
• 18:56
  William Auten: He's binge listening.
• 18:57
  William Auten: Well, he's watching on YouTube.
• 18:59
  Chantal Roberts: Oh art, I love you.
• 19:04
  William Auten: I was gonna bring a picture of him uh to show in the background, but uh you should.
• 19:10
  Chantal Roberts: We should do that next time.
• 19:12
  Chantal Roberts: Hi, Art.
• 19:14
  William Auten: Um maybe he'll maybe he he we can have him join us uh at some point.
• 19:19
  Speaker 3: That would be fantastic.
• 19:20
  William Auten: No, that'd be dangerous.
• 19:21
  William Auten: Art is a character.
• 19:22
  William Auten: We love art.
• 19:24
  Chantal Roberts: We love art though.
• 19:25
  William Auten: We like him off camera though, I think.
• 19:28
  Chantal Roberts: Do we though?
• 19:29
  Chantal Roberts: Um, you know, I gotta tell you, from my expert witness perspective, uh, because we're talking about this assumption and everything, I know that I have to be ultra aware of when I am walking in on uh a case with an assumption.
• 19:45
  Chantal Roberts: And I probably should not admit to this, but I kind of always look at it that okay, the injured or the insurer handled the claim correctly.
• 19:58
  Chantal Roberts: And then I go in looking for what mistakes they made, which is probably not the way that I should do it.
• 20:06
  Chantal Roberts: I should probably go in looking, you know, just 100% independent.
• 20:11
  Chantal Roberts: But I tend to find those mistakes because you you tend to find if you're looking for something.
• 20:18
  Chantal Roberts: And that's not to say that I'm always hired by the plaintiff attorneys.
• 20:22
  Chantal Roberts: I mean, I'm hired by defense firms as well.
• 20:25
  Chantal Roberts: And I find things where I'm like, you know, you may you may want to go ahead and settle this.
• 20:30
  Chantal Roberts: And then I've told plaintiff attorneys many, many times, like, yeah, yeah, I don't uh they really didn't do anything wrong.
• 20:37
  Chantal Roberts: I mean, yes, there were some mistakes.
• 20:39
  Chantal Roberts: And by the way, adjusters, I think adjusters are so scared of this.
• 20:43
  Chantal Roberts: You can make mistakes, you just can't make them deliberately, like willful, wanton, and right and that sort of thing.
• 20:52
  Chantal Roberts: Um, and and that I think is where the danger and assumption comes up.
• 20:58
  William Auten: Yeah.
• 20:59
  William Auten: People don't want to admit when they have to change their perspective on something or change their opinion or change their mind, or yeah, or or they, you know, they hold on to a belief so firmly, yeah, it's hard to let it go.
• 21:12
  William Auten: And and for some people, it could put them in a state where they're being a little dishonest to try and protect their opinion of something.
• 21:22
  Chantal Roberts: Or they just completely ignore new facts.
• 21:26
  Chantal Roberts: And and again, I've seen this being hired by the defense when I see the adjuster with the insured giving them new facts and new information, the adjuster still just shuts down.
• 21:41
  Chantal Roberts: Yeah, just instead of keeping their mind open, has already made the assumption that there cannot be this amount of damage from whatever kind of loss there was, and therefore I'm not gonna accept it.
• 21:57
  William Auten: It's it's hard for like
• 22:00
  Chantal Roberts: Yeah.
• 22:00
  Chantal Roberts: It's very we're all human.
• 22:02
  William Auten: We are human.
• 22:03
  William Auten: And um boy, I I j I'm thinking of all the cases that that we've had where um where the tide turns on one bit of information.
• 22:15
  William Auten: I can think of one where we had a case pretty much locked down for a liability denial, and our insured signed an affidavit that you know she um she wasn't aware of these circumstances that were on the property.
• 22:29
  William Auten: And she she nobody ever told her that this was going on.
• 22:33
  William Auten: And um she signed an affidavit.
• 22:36
  William Auten: And we're like, this locks it up.
• 22:38
  William Auten: Well, they sued it, they deposed her for I don't know how long the deposition was, but eventually they got her to admit that yes, she actually did know about that condition.
• 22:50
  William Auten: So now the whole complete, you know, reversal of liability.
• 22:57
  William Auten: And um what are you gonna do?
• 22:59
  William Auten: Yeah, you know, I mean, we we as adjusters do what we can.
• 23:04
  William Auten: Am I gonna sit and depose somebody for hours and hours until uh but the thing the thing is that um the the other side in that case had a vested interest in in pushing as hard as they could to get her to change her story.
• 23:21
  William Auten: Now, which was you know, did she change her story because she was sick of getting questioned, or did she, you know, I don't know, I wasn't there during the deposition.
• 23:31
  William Auten: All I know is that um I was told that whatever she said in the affidavit we found to be refuted uh during the deposition.
• 23:40
  William Auten: And you just throw your hands up, what are you gonna do, right?
• 23:43
  William Auten: And was she lying to me, or did she not fully understand what I was asking?
• 23:49
  William Auten: Or, you know, I don't know.
• 23:51
  Chantal Roberts: Um you know, here's something else that I think adjusters don't necessarily know, and I I think that they should understand people are gonna lie to you, and there's nothing you can really do about that.
• 24:07
  Chantal Roberts: You can only work on the information that you have, and so if they're going to lie to you for, and I'm not saying that insured was lying, I'm not saying that right.
• 24:17
  William Auten: Yeah, and I don't know that she was either.
• 24:19
  William Auten: Um, I don't think she was.
• 24:21
  William Auten: I think what it was is there was a either she she had a memory that didn't come back until she was heavily questioned about it, right?
• 24:31
  William Auten: Um, or or perhaps her own assumptions and her own confirmation bias erased uh something in her memory about that.
• 24:41
  William Auten: Um but I mean, I look, we've all joked about my memory not being rock solid.
• 24:50
  William Auten: You know, I I I can swear I put my glasses on one table and I'll walk through the whole house looking for them and they'll be on another table, you know.
• 24:59
  William Auten: That happens um uh with everybody, you know.
• 25:03
  William Auten: I think we all get distracted and uh it doesn't make you a liar, it makes you just um it makes you human.
• 25:10
  William Auten: Makes you human, I guess.
• 25:11
  Chantal Roberts: Yeah, exactly.
• 25:13
  Chantal Roberts: Um, which is probably the the subtitle of our um podcast today.
• 25:18
  Chantal Roberts: So there's five dangerous kinds of assumptions that we have, and and one of them I think was the fact that um you had mentioned earlier that oh, everything is kind of a fraud, um or whatever, like maybe that ownership of this belief um or ownership of a building or or something like that.
• 25:41
  Chantal Roberts: Oh, we assume that the insured owns the building, so we're not gonna look at a deed or something, you know, like that, or there's maintenance agreements.
• 25:52
  Chantal Roberts: You can't necessarily assume all of that.
• 25:55
  Chantal Roberts: Um even if the insured, because I see this all the time, even if the insured is a person who owns the building where they own the the company that is renting the building from the person.
• 26:07
  Chantal Roberts: Well, I still kind of want to see your rental agreement, you know, kind of deal.
• 26:10
  Chantal Roberts: Um, what are some of the other dangerous assumptions uh that that adjusters can have?
• 26:19
  William Auten: Um that the insured is uh automatically adverse to you, that they think that you're out to get them or that you're you're gonna you're out to screw them over.
• 26:29
  Speaker 3: Or the claimant.
• 26:30
  William Auten: Um or the claimant.
• 26:32
  William Auten: Um and that goes both ways.
• 26:35
  Speaker 3: Yeah, yeah, yeah.
• 26:36
  William Auten: Uh you know, sometimes a policy holder does have that assumption about the adjuster, and the adjuster's not you know intent on doing that at all.
• 26:45
  William Auten: Um I find I find more adversity with policy holders in first party claims than in um um liability claims.
• 26:59
  Chantal Roberts: Yeah, I think that's right.
• 27:01
  William Auten: Yeah.
• 27:01
  Chantal Roberts: I think that's right.
• 27:02
  Chantal Roberts: Uh because we hear so often about in insureds who uh have a neighbor who's has the same kind of damage and their insurance company is paid, and this insurance company that this the insured has is just like nickel and diamondum or whatever.
• 27:25
  Chantal Roberts: So we hear these horror stories, and that is a problem for the insurance industry itself to fix.
• 27:33
  Chantal Roberts: Uh, I don't think you and I could possibly fix it.
• 27:37
  Speaker 3: Yeah.
• 27:37
  Chantal Roberts: But um, this is something that this is an assumption that adjusters need to walk in knowing about.
• 27:43
  Chantal Roberts: Um, so maybe notice would be a good thing, like know that um an insured or a claimant may be adversarial to you, and you would need to spend some extra time with them by uh, you know, taking care of their fears and explaining the process uh so that people are not adversarial to you.
• 28:08
  William Auten: Yeah.
• 28:09
  William Auten: Um it's funny that the difference between first party and third party, um, the dynamics, and and I think it's because on the first party side you're you're more dealing with a customer than you are with parties to a dispute.
• 28:28
  William Auten: And that's like in the third party, that's kind of what you're really dealing with.
• 28:32
  William Auten: There is an expectation on the insurance part that they're going to be protected, um, but it's not as admitting immediate as on the property side where they feel like they've paid in X amount of dollars and they want some, you know, they want their pound of flesh out of that.
• 28:49
  William Auten: I was just thinking that word.
• 28:52
  William Auten: Pound of flesh.
• 28:56
  Chantal Roberts: Anyway, so like a hundred episodes later, and we're just gonna do mind melds into um and art, you just need to catch up.
• 29:10
  William Auten: I was uh I I saw that I was called your energetic um guest.
• 29:15
  William Auten: Energetic guest, yes.
• 29:16
  William Auten: I'm your energetic guest.
• 29:19
  Chantal Roberts: I'm like, oh no.
• 29:20
  William Auten: I'm not even that energetic.
• 29:21
  Chantal Roberts: Um I'm like, no, he's like my co-host.
• 29:24
  Chantal Roberts: So yeah.
• 29:26
  William Auten: Um another another thing, um, another assumption that's dangerous um is that you assume that this incident, this is I'm I lean third party.
• 29:37
  William Auten: So this is a a third party situation where you listen to the story of a claimant who got hurt and you make the assumption that nobody saw it.
• 29:47
  William Auten: And yeah, you don't believe them because nobody saw it.
• 29:51
  William Auten: Right.
• 29:51
  William Auten: Um, you better ask if someone saw it.
• 29:54
  William Auten: You better ask if there's footage of it.
• 29:57
  William Auten: Because if you assume that this person is making it up and there's a video floating around there somewhere that you know their attorney finds and brings to court someday, you're gonna look kind of foolish.
• 30:09
  Chantal Roberts: Let's talk about videos real quick.
• 30:11
  Chantal Roberts: And this would be a great podcast, by the way, of where to look for additional information because we are so recorded now and we don't even realize it.
• 30:23
  Chantal Roberts: Uh, there are cameras on, you know, traffic cameras.
• 30:26
  Chantal Roberts: Uh, my husband just pointed out a camera that goes into and out of the dog park that we that we use that records your license and then your face as you're leaving.
• 30:38
  Chantal Roberts: Uh, there are ring cameras.
• 30:40
  Chantal Roberts: I I don't know if any of our listeners uh go to next door.
• 30:46
  Chantal Roberts: I love reading all of the spicy comments and uh people spilling the tea on next door.
• 30:54
  Chantal Roberts: Next door app, the app called Next Door.
• 30:57
  Chantal Roberts: Yeah, we should get them to be our sponsor.
• 30:59
  Chantal Roberts: Um who uh we, you know, I I see these these women who are like, Who are these kids?
• 31:07
  Chantal Roberts: You know, and they'll or who's this person who's you know trying my door at 10 p.m.
• 31:13
  Chantal Roberts: or whatever.
• 31:14
  Chantal Roberts: And so we're recorded quite a bit.
• 31:17
  Chantal Roberts: And my husband was telling me about uh some some thefts uh recently where a guy stole, I think like a $15,000 Patrick Mahomes uh card, football card.
• 31:32
  Chantal Roberts: And there's just there's recordings all over for him and uh of him doing it.
• 31:38
  Chantal Roberts: So be sure to ask, like if you get that claim, go okay, great.
• 31:44
  Chantal Roberts: Where were you?
• 31:45
  Chantal Roberts: Who has that you you know recording and get that?
• 31:50
  William Auten: Yeah, and don't uh discount the things across the street, you know.
• 31:55
  Chantal Roberts: Oh, yeah, absolutely.
• 31:56
  Chantal Roberts: Well, and it's called canvassing.
• 31:58
  Chantal Roberts: We have talked very briefly about canvassing, and I don't know if it's done much anymore.
• 32:04
  Chantal Roberts: You're an independent.
• 32:05
  Chantal Roberts: I don't know if if you do much canvas.
• 32:07
  Chantal Roberts: Oh, sure.
• 32:08
  Chantal Roberts: Okay, good.
• 32:09
  Chantal Roberts: But okay, so if you don't know what canvassing is, you just tell the independent to go like, okay, the accident happened at fifth and main, walk around to all of the businesses around or the homes around Fifth and Main, knock on their door and ask if anybody saw it.
• 32:23
  William Auten: Yeah, you can't you can't be afraid to walk up to strangers and talk to them.
• 32:26
  William Auten: Uh that's that's the kind of the trick.
• 32:29
  William Auten: And there's other tricks that that I have that I won't share here because you'd have to pay me.
• 32:34
  William Auten: Um but um uh but there's some things you can do to get people to talk um if they if they know something.
• 32:41
  Speaker 3: Yeah.
• 32:42
  William Auten: And uh sometimes people just clam up and they just won't say anything.
• 32:46
  William Auten: But um exactly other times you'll find that they won't shut up.
• 32:51
  William Auten: I took a statement from a guy just uh recently.
• 32:54
  William Auten: He claims to have known everything there is to know about it.
• 32:57
  William Auten: He's talked to the claimant a million times, he knows exactly what happened.
• 33:01
  William Auten: I start questioning him.
• 33:03
  William Auten: He was talking about something completely different that had nothing to do with the incident at hand.
• 33:11
  William Auten: But that happens too.
• 33:13
  Chantal Roberts: That does too.
• 33:14
  Chantal Roberts: Another dangerous assumption for adjusters is again when we're talking about I I had mentioned uh ownership, but also control.
• 33:21
  Chantal Roberts: We've talked a lot about, especially when we're doing what you talk about snow removal.
• 33:27
  Chantal Roberts: Um, and again, this comes with the contracts, knowing who does what, when, what the contract says.
• 33:34
  Chantal Roberts: Uh, don't make assumptions that you have to um or or so and so has to do something about it.
• 33:43
  Chantal Roberts: An excellent example again from 530, CPCU 530, the legal environment is one of the questions talks about a a person who trips on a sidewalk uh in front of a store, a general store.
• 33:56
  Chantal Roberts: And they're asking who has liability for that.
• 34:00
  Chantal Roberts: Well, one of the answers is it was the store.
• 34:03
  Chantal Roberts: One of the answers it's the city, and everybody picks the store because that's what most municipalities say.
• 34:10
  Chantal Roberts: And I'm like, yeah, but we can't not all of them, yeah, we can't assume that, guys.
• 34:16
  Chantal Roberts: So the answer is technically the city, right?
• 34:19
  Chantal Roberts: And they're like, but but and I'm like, I know, I know, but you've got to turn off your brain and and approach it with this, you know, new new mind or whatever.
• 34:31
  Chantal Roberts: Um, also causation.
• 34:33
  Chantal Roberts: This is what I was getting into, not arguments, but I was pressing the assumptions of my students because I gave the example of a wobbly floor.
• 34:46
  Chantal Roberts: I said, you know, there's a floorboard that wobbles, so-and-so was drinking a lot, they tripped and fell over this wobbly floorboard.
• 34:55
  Chantal Roberts: Nobody else tripped and fell.
• 34:59
  Speaker 3: Right.
• 34:59
  Chantal Roberts: Who's at fault?
• 35:01
  Chantal Roberts: The person who's drunk or the insured who owns the wobbly floor?
• 35:05
  Chantal Roberts: I mean, is the wobbly floorboard really gonna get you?
• 35:08
  Chantal Roberts: I mean, if no one trips before, no one trips after.
• 35:12
  Chantal Roberts: And then I also used the example that we always think about is like the grape on the grocery store.
• 35:20
  William Auten: Yep.
• 35:21
  Chantal Roberts: Uh, they understood that one a little bit better than the wobbly floorboard.
• 35:24
  Chantal Roberts: I'm like, why'd you step on the grape if you saw it?
• 35:28
  William Auten: Right.
• 35:29
  William Auten: Um, I had uh I had a story about it, wasn't my claim, uh, but it was a story about a person who uh was in a department store and there was something that had fallen off the shelf or somebody dropped in the middle of the aisle, and this person tripped over it and fell.
• 35:46
  William Auten: And they want to blame the store.
• 35:48
  William Auten: Kind of open and obvious.
• 35:51
  William Auten: Hello.
• 35:52
  William Auten: Like you can walk around things.
• 35:54
  William Auten: Uh, I think that the personal responsibility, you know, we've said this a million times, and everybody seems to agree with this that uh there should be people need to account for personal responsibility.
• 36:07
  William Auten: You need to guide yourself through life so that you can avoid hazards if you see them.
• 36:12
  William Auten: Yes, um, and of course, we can't we can't avoid all of them.
• 36:17
  William Auten: No, and that's what you know makes my job, you know, but yeah, yeah.
• 36:23
  William Auten: That's that's what's that's back to contracts, real quick.
• 36:27
  William Auten: Uh um Yeah.
• 36:28
  William Auten: New York is um, we've got this labor law 240, uh, and that holds uh commercial projects, construction projects.
• 36:36
  William Auten: It holds the general contractor and property owner strictly liable if someone falls from a height or something falls from a height on them.
• 36:44
  William Auten: That's the real big nutshell uh 30,000 foot view of labor law 240.
• 36:50
  William Auten: Um so we get a claim involving uh a staircase collapse on a construction site where somebody got hurt.
• 36:59
  William Auten: Agent sends it over.
• 37:00
  William Auten: This should be sent directly to the general contractor, they're fully responsible for this.
• 37:06
  William Auten: Okay.
• 37:07
  William Auten: We ensure the owner.
• 37:08
  William Auten: But but uh this is New York, this is a commercial project.
• 37:13
  William Auten: Um the owner has responsibility too, and the only way that they can pass it off to that GC is uh through contracts if there's a defense and indemnity agreement.
• 37:22
  William Auten: Exactly.
• 37:23
  William Auten: So I'm assuming, jokingly, I'm assuming that this agent knows that there's defense and indemnity and hold harmless agreements in the contract with that general contractor.
• 37:35
  William Auten: So I call the insured and say, can you send over the the full agreement for me?
• 37:40
  William Auten: He sends over the four-page agreement.
• 37:42
  William Auten: Nowhere in there is there anything about defense and indemnity, and there's an addendum.
• 37:48
  William Auten: Oh no, and the addendum says this speaks to um uh this addendum details insurance requirements and defense and indemnity requirements.
• 37:59
  William Auten: They never wrote the addendum, there's no addendum.
• 38:03
  Chantal Roberts: Oh no.
• 38:05
  William Auten: Well, bless their hearts, bless their hearts, bless their hearts.
• 38:09
  William Auten: That's what that can happen if you assume that contracts exist.
• 38:14
  Chantal Roberts: Yeah, and so that leads to damages, actually, which is another one of our assumptions.
• 38:20
  Chantal Roberts: And and what that is, uh, you know, just because you, I don't know, slip and fell, uh, and you hit your head does not mean that that falling created a traumatic brain injury.
• 38:37
  Chantal Roberts: Maybe they had it before.
• 38:38
  Chantal Roberts: Maybe there was an intervening causation that did this.
• 38:43
  Chantal Roberts: Maybe they fell a second time.
• 38:44
  Chantal Roberts: I don't, I don't know.
• 38:46
  Chantal Roberts: Or that they were involved in a car accident and you know, the seatbelt came and you know, the shoulder got hurt or whatever, and that required surgery.
• 38:55
  Chantal Roberts: I don't know.
• 38:56
  Chantal Roberts: Again, don't assume that everything's there.
• 39:00
  Chantal Roberts: You've got to read these medical bills, you've got to talk to people again.
• 39:03
  William Auten: And if you're a claimant, don't assume you're gonna get five million dollars because you saw it in a commercial.
• 39:08
  Chantal Roberts: Don't.
• 39:09
  Chantal Roberts: Yeah.
• 39:10
  Chantal Roberts: Yeah.
• 39:10
  Chantal Roberts: So we're talking a lot about assumption, and I know a lot of people are sitting there going, but Bill and Chantel, I mean, I can kind of infer or, you know, think about draw the logical conclusion that this is what happens.
• 39:28
  Chantal Roberts: And so yeah, you're right.
• 39:29
  Chantal Roberts: We have to make these inferences, but in our investigation, can't just like go on indefinitely.
• 39:37
  Chantal Roberts: I mean, we have to make a decision, we have to pull the trigger somewhere, somehow.
• 39:41
  Chantal Roberts: Um, we can't go down all the rabbit holes.
• 39:46
  William Auten: That's really the name of the game, is we're in a decision-making game.
• 39:49
  William Auten: Right.
• 39:50
  William Auten: And and there are some time deadlines associated with that.
• 39:55
  William Auten: Um, there might be some statutory deadlines where you've got a certain number of days to issue a letter, you know, uh, or uh make a decision on coverage or make a decision on on the claim in its entirety because the statute of limitations applies.
• 40:14
  William Auten: Three years here in New York.
• 40:16
  William Auten: Um, so you know, it may we have a lot of cases that you don't know all the facts yet because treatment hasn't been completed, or there are witnesses that you're still trying to find that have moved, and it's not that they've vanished, they're there.
• 40:33
  William Auten: You just gotta find them.
• 40:34
  Speaker 2: Exactly.
• 40:35
  William Auten: And you may run out of time.
• 40:37
  William Auten: And um, when you don't have that evidence that you really need to make um a decision with a higher confidence level than you are at today, you still gotta, like you say, pull the trigger and do something.
• 40:53
  Speaker 3: Yeah.
• 40:53
  William Auten: Um and do you always get it right?
• 40:56
  William Auten: No, you hope so.
• 40:58
  William Auten: Uh, you have to make the best educated guess that you can.
• 41:02
  William Auten: Um, but that's not that's not making assumptions.
• 41:06
  William Auten: That's that's compiling all the facts that you can gather um and and and um uh digging the well as far as deep as you can to make those decisions.
• 41:20
  William Auten: And then once you're satisfied that you can't dig anymore, you got to take what you have, lay it out on the table, and say, okay, what are we gonna do here?
• 41:29
  Chantal Roberts: Right, right.
• 41:30
  Chantal Roberts: So, you know, you you usually get a loss notice that says something like claimant tripped over a raised sidewalk, for example.
• 41:39
  Chantal Roberts: Uh, that's the assumption that that people have.
• 41:42
  Chantal Roberts: Uh the inference, I suppose, would be that there are people who saw this, you know, that the claimant fell or tripped over the raised sidewalk.
• 41:54
  Chantal Roberts: Uh, there's video that shows this.
• 41:57
  Chantal Roberts: The the statement is the claimant states her foot caught on the the lip of the sidewalk that was raised.
• 42:06
  Chantal Roberts: And if you if you've got video or if you got witnesses, you know, she fell at 2 14 p.m.
• 42:13
  Chantal Roberts: on Monday, you know, August 8th or whatever.
• 42:18
  Chantal Roberts: So yeah, that's the difference between inference and assumptions, I would think.
• 42:25
  William Auten: I w yeah.
• 42:25
  William Auten: So when you say inference, my mind goes to an educated guess.
• 42:29
  William Auten: That's what I think of immediately.
• 42:31
  William Auten: When you say assumption, it sounds like a wild person who's uh just got confirmation bias embedded in their brain that they can't get out.
• 42:42
  William Auten: Um it's almost like a virus.
• 42:45
  Chantal Roberts: Yeah, yeah, yeah.
• 42:46
  Chantal Roberts: Yeah.
• 42:47
  Chantal Roberts: And then if you if you continue to operate on that assumption rather than gathering these facts, that's when I kind of get the the file later, uh, which is, I mean, I always want to put myself out of business.
• 42:59
  Chantal Roberts: So it's one of the reasons why we do this.
• 43:01
  Chantal Roberts: But and maybe I'm doing a really good job because by the way, I haven't gotten any business like this, but that's okay.
• 43:10
  Chantal Roberts: Maybe I'm doing a great job.
• 43:11
  Chantal Roberts: Woo!
• 43:13
  William Auten: Well, you know, uh people do make in this business, people do make bad decisions, you know.
• 43:19
  William Auten: And and it might be because there's just not enough information available at the time, or it could because be because they're making bad assumptions.
• 43:29
  William Auten: Um, as art would say, they were wearing their bad decision pants.
• 43:35
  Chantal Roberts: I didn't even know there were bad decision pants.
• 43:36
  Chantal Roberts: Thank you.
• 43:37
  William Auten: Oh, yeah.
• 43:38
  William Auten: Oh yeah, he he's got several pairs.
• 43:40
  Chantal Roberts: Oh, okay.
• 43:41
  Chantal Roberts: I know quite a few people who have several pairs.
• 43:44
  Chantal Roberts: All right.
• 43:45
  Chantal Roberts: Um, yeah, so when I get the the file, I think I kind of talked about this.
• 43:51
  Chantal Roberts: I I do kind of go in with an assumption, uh, but I start looking for contrary.
• 43:59
  Chantal Roberts: Information.
• 44:01
  Chantal Roberts: Uh, you know, so I usually hope that, well, I do hope, I hope that the insurer has done the file correctly, has handled the file correctly.
• 44:12
  Chantal Roberts: And either I will find evidence that they have or I find evidence that they haven't.
• 44:17
  Chantal Roberts: I can equally, I suppose, go in with the the idea that the insurer had not handled the file correctly and look at it from that point of view.
• 44:28
  William Auten: Uh it's a really good exercise to uh take the opposite um opinion, um, especially if you have uh the ability to have a round table or a mock trial, for example.
• 44:41
  William Auten: Yes.
• 44:42
  William Auten: Where you give somebody the assignment and and you say, here's here's all the information we have.
• 44:49
  William Auten: You are going to take the opinion that it happened this way, and then over here, this person is going to take the opposite position and stress test of how those facts might apply.
• 45:03
  Chantal Roberts: Exactly.
• 45:04
  Chantal Roberts: Because again, one of the things that we need to be remembering is we've got a contract of adhesion, which means our contract is written by the the carrier.
• 45:15
  Chantal Roberts: And if there's a a different interpretation of a word or something, then we have to grant authority or or coverage to the insured.
• 45:23
  Chantal Roberts: Now that is a property damage aspect, but the same thought process could be going over to liability, I believe.
• 45:32
  Chantal Roberts: Like, you know, if we're looking at this from a claimant's point of view, blah, blah, blah, if we're looking at it from an insured's point of view, this would happen.
• 45:40
  William Auten: Uh so I I totally agree that there's gray areas on the liability uh coverage side too.
• 45:47
  William Auten: Um, you know, things happen that um where you get into uh take motor vehicles, you know, and you've got UTVs, ATVs, motorcycles.
• 45:58
  William Auten: Um are they all excluded?
• 46:01
  William Auten: Always, always excluded?
• 46:03
  William Auten: Uh you know, what what is the um what's the bright line?
• 46:08
  William Auten: And there are some uh bright lines of uh relating to motor vehicles, um, but at some point you're gonna come across a situation that is marginal and the policy language doesn't really um apply to it in a clear black and white sense.
• 46:28
  William Auten: And um in a case like that, you're gonna have to you're gonna have to take that um that theory that the con that the insurance policy is a contract of adhesion.
• 46:40
  William Auten: The uh um what do I want to say?
• 46:43
  William Auten: A uh not a discrepancy, what's the word?
• 46:45
  William Auten: Ambiguities are going to be decided in favor of the policy holder or the party that did not draft the document.
• 46:53
  Speaker 3: Right.
• 46:54
  William Auten: There's probably a better way to say all that, but I think I got it out.
• 46:57
  Chantal Roberts: No, you did, you got it all out, yeah.
• 46:59
  Chantal Roberts: You know, documentation, uh when when we're talking about that kind of thing with assumptions, sometimes even helps the original adjuster to go back and reread the entire file.
• 47:14
  Chantal Roberts: Uh because sometimes you're like, oh, I was just in a bad mood that day.
• 47:19
  Chantal Roberts: I don't interpret it that way anymore because because I see this a lot of times in files, and uh you and I've talked about it before, where I'm just screaming at the computer, my you know, expert witness file, going, pick up the phone.
• 47:36
  Chantal Roberts: Just pick up the phone.
• 47:38
  Chantal Roberts: And and I get it, the adjusters are busy and they think, oh, I can just write this down, but the insured still has questions.
• 47:46
  Chantal Roberts: And and seven emails later, they're missing the actual point.
• 47:51
  Chantal Roberts: And so now you're in a bad mood, you're misinterpreting things because you can't interpret tone and and that.
• 47:58
  Chantal Roberts: So something becomes obvious in hindsight five years down the road to me that may not be obvious to the adjuster.
• 48:08
  Chantal Roberts: And again, that's that's an assumption that we have to look at and go, yeah, what you know, adjuster, what should you be doing?
• 48:17
  Chantal Roberts: And it's hard to catch yourself.
• 48:18
  Chantal Roberts: I'm gonna tell you, it's hard to catch yourself in the heat of the moment.
• 48:22
  William Auten: Yeah, I would say that um I don't I don't want to say it's okay to get something wrong, because you want to avoid that, but the it but it is inevitable that throughout your work you're going to you're gonna make a decision that ultimately was the bad decision because you didn't have all the information.
• 48:44
  Chantal Roberts: And never going to have all the information, yeah.
• 48:48
  William Auten: And and um, you know, and sometimes uh plaintiff attorney will hold on to information or assume that you know it.
• 48:56
  William Auten: I've had that happen a lot where they just assumed that I I knew this bit of information that we had no idea.
• 49:04
  William Auten: Like, how would we ever know this?
• 49:06
  William Auten: You know?
• 49:06
  William Auten: Um and then once we do have that information or documentation or whatever, it really changes the tide.
• 49:15
  unknown: Yeah.
• 49:16
  William Auten: So a message out to plaintiff attorneys make sure you're helping the adjuster make the decision.
• 49:21
  William Auten: If you're if you're uh holding hostage uh evidence that could help us make a good decision earlier rather than later, it benefits everybody.
• 49:31
  Chantal Roberts: Yeah, because we can only make the decision that's that we have in the file.
• 49:36
  Chantal Roberts: And if our insured said we didn't do it and your client says you did do it, and you're holding on to that proof.
• 49:43
  Chantal Roberts: Or I mean, I would much rather have things in duplicate or triplicate than not at all.
• 49:51
  William Auten: Right.
• 49:52
  Chantal Roberts: Both as an expert witness and as uh as a claims adjuster, because that's how you you become fair and unbiased in that particular thing.
• 50:03
  William Auten: Yep.
• 50:03
  William Auten: Um yeah, and avoid being a right fighter, meaning that you think you're right and you're gonna fight to the death to support that opinion of yours.
• 50:13
  William Auten: Um, you know, give yourself the grace to um be wrong.
• 50:21
  Chantal Roberts: Yeah, and and you know, you may want to just again go in with the idea of, okay, so I don't know anything about this.
• 50:29
  Chantal Roberts: What information do I need?
• 50:33
  Chantal Roberts: Instead of always assuming, hey, our insured is always right, or the claimant is always wrong, or the claim or or claims in general are fraud.
• 50:43
  Chantal Roberts: You know, everybody's just trying to to get one over the insurance company or or whatever.
• 50:49
  Chantal Roberts: It may happen, it may not happen, but there have to be documented solid facts, not your assumptions.
• 51:01
  William Auten: Right.
• 51:02
  Chantal Roberts: Yeah, I was looking at a case, for example, uh expert witness case, and the uh insured was upset that they were turned over to special investigations unit, SIU, for fraud.
• 51:18
  Chantal Roberts: And I had when I wrote my report, I said, look, you know, usually as an as an adjuster, when we see three red flags, that's usually when we report it.
• 51:30
  Chantal Roberts: One or two, no, we're not gonna turn it over into SIU.
• 51:34
  Chantal Roberts: But if we see three or more, then yeah, we're gonna turn it over to SIU.
• 51:38
  Chantal Roberts: And the insured doing this, the insured doing this, the insured doing this, the insured doing this.
• 51:46
  Chantal Roberts: These are four things that are typical red flags that we all learn about when we take our fraud training.
• 51:52
  Chantal Roberts: So the adjuster did the correct thing by turning this over to the fraud department or the SIU department, you know.
• 52:00
  Chantal Roberts: So have those facts and of course write those into the file notes, guys.
• 52:07
  William Auten: Yep.
• 52:08
  Chantal Roberts: Gotta write them into the file notes.
• 52:10
  William Auten: Yeah, don't assume that everybody knows something that you just heard on the phone.
• 52:14
  William Auten: Yeah.
• 52:14
  William Auten: Uh document it and uh make sure that there's a record of it.
• 52:19
  Chantal Roberts: Yeah.
• 52:19
  Chantal Roberts: So what about you in your field investigations?
• 52:22
  Chantal Roberts: What do you what do you run into?
• 52:26
  William Auten: Um, as far as um assumptions or assumptions.
• 52:30
  Chantal Roberts: What's your what's your perspective?
• 52:32
  Chantal Roberts: Because I mean, we talked about me.
• 52:33
  William Auten: There's a lot of um coverage assumptions.
• 52:36
  William Auten: Uh assuming that something is or is not covered.
• 52:39
  William Auten: Um, I think that um that happens a lot.
• 52:42
  William Auten: I think probably more on the first party side than the third party.
• 52:46
  William Auten: Um one I I one that comes to mind is is fairly minor, but this happens where someone decides to um buy a second home and they Airbnb their home or they rent it to somebody and they don't get any kind of endorsement for that.
• 53:05
  William Auten: Um, if they're not living in the property, if it's not their residence premises, there's no cover.
• 53:12
  William Auten: The coverage terminates, you know.
• 53:14
  Chantal Roberts: And um an HO3 or an HO policy does not work for a second home, guys, just FYI.
• 53:21
  William Auten: Right.
• 53:21
  William Auten: So that person might assume that they have coverage if there's damage while they're living in their other house and renting their existing house.
• 53:31
  William Auten: Um uh that's a bad assumption.
• 53:34
  Speaker 3: Yep, yep.
• 53:35
  William Auten: And then uh the opposite is true where the carrier may get that claim in and just assume that it's covered until the adjuster goes out and finds that there's actually a tenant living there uh instead of the named insured.
• 53:50
  William Auten: Oh no, we're renting the place.
• 53:51
  William Auten: Oh, how long have you been renting it?
• 53:53
  William Auten: Oh, about two years.
• 53:54
  William Auten: Oh, really?
• 53:56
  Chantal Roberts: Uh my dad worked a claim once where the adjuster had called him and said, Hey, I um need you to look at this piece of equipment because you know, take pictures of it, get some information on it, blah, blah, blah.
• 54:12
  Chantal Roberts: There's not going to be any coverage.
• 54:13
  Chantal Roberts: It was a cherry picker.
• 54:15
  Chantal Roberts: Uh, and I think a liability claim, and cherry pickers are specific one of the exceptions to the exclusions for mobile equipment.
• 54:25
  Chantal Roberts: And and so dad was talking to the insurance adjuster, and he's like, you know, that there's actually coverage because it's the exception to the exclusion.
• 54:34
  Chantal Roberts: And so that's one of the reasons.
• 54:36
  Chantal Roberts: Again, you can't make these assumptions.
• 54:38
  Chantal Roberts: You got to read the policy, of course, but also your IAs may be able to help you.
• 54:42
  Chantal Roberts: So listen to them.
• 54:45
  William Auten: Devil's in the details, man.
• 54:47
  Chantal Roberts: Yeah, yeah.
• 54:48
  Chantal Roberts: Um, and also read those contracts just like you did with the insured who had who was doing some construction.
• 54:58
  Chantal Roberts: Well, they weren't in construction, you know, but they hired construction and yeah, strict liability, they're responsible.
• 55:06
  William Auten: So yeah.
• 55:07
  Chantal Roberts: Um, even though they weren't swinging the hammer or whatever.
• 55:10
  William Auten: Well, uh, another thing that um that you could um fail to recognize if you're assuming the wrong thing is that coverage might exist where you wouldn't expect it.
• 55:22
  Speaker 2: Oh, yeah.
• 55:22
  William Auten: Uh, we we have we deal with property managers a lot, and most commercial liability policies add a property manager as additional insured.
• 55:32
  William Auten: Not they don't specifically name them, but it's in the language of the policy that uh under the definition of an insured, a real estate manager is considered an insured.
• 55:43
  William Auten: And um, you know, if that real estate manager gets named in the lawsuit, you know, you may have to defend and indemnify them also.
• 55:53
  Chantal Roberts: Very good, very good point.
• 55:55
  Chantal Roberts: Yeah.
• 55:55
  Chantal Roberts: Uh so how do you think that we would stop?
• 56:00
  Chantal Roberts: Like, what was the best piece of information or advice that you would give to adjusters to say, hey, um, you know, let's stop assuming things.
• 56:12
  William Auten: I would say you may allow yourself to assume this all the time.
• 56:17
  William Auten: Assume you don't have all the facts.
• 56:19
  William Auten: I think that's and if you if you keep that assumption, I think you'll be okay.
• 56:25
  William Auten: Right.
• 56:25
  William Auten: It's the anti-assume law.
• 56:29
  Chantal Roberts: Yeah, the anti-assume law.
• 56:30
  Chantal Roberts: I like that.
• 56:31
  Chantal Roberts: Uh yeah, or just understand that that you know that you don't know everything.
• 56:36
  Chantal Roberts: Uh you you won't always have all of the information, and and you have to get comfortable not knowing all the pieces of information, and you have to be comfortable pulling the trigger not knowing all of the information.
• 56:51
  Chantal Roberts: But you you you also need to go in, like I said, with a beginner's mind.
• 56:55
  Chantal Roberts: That's that's the way that I I tell people.
• 57:00
  William Auten: Um learn something in this job every day, and I've been doing it a long time.
• 57:04
  William Auten: Absolutely.
• 57:05
  William Auten: My my my team, they all learn something new every day, also.
• 57:10
  Chantal Roberts: Yeah, yeah.
• 57:11
  Chantal Roberts: So, you know, our job as adjusters, it's not to make the facts fit the claim, right?
• 57:19
  Chantal Roberts: So you take all the facts and then you you just take the four corners of the policy and and see if it lines up.
• 57:27
  Chantal Roberts: If it lines up, then there's coverage or uh then you can move on if you're doing a liability claim and and see if the ABCD rule matches with with liability.
• 57:39
  Chantal Roberts: And if that works, then you pay the claim.
• 57:42
  Chantal Roberts: Now that's not to say again that more things won't happen, but you know, our job is to find out what the facts actually are and to be clear about what we don't know, what someone told us, gotta write all that stuff down, what the evidence suggests.
• 57:57
  William Auten: Don't show up to work wearing your bad decision pants.
• 58:00
  Chantal Roberts: Don't ever do that.
• 58:01
  Chantal Roberts: That is so bad.
• 58:03
  Chantal Roberts: Um, yeah, because it might we might end up talking about it in episode 102, which is gonna be in two weeks.
• 58:12
  Chantal Roberts: Yeah, where we talk about the uh million dollar file actually starts on day one.
• 58:19
  Chantal Roberts: And yeah, I I have seen that where it's just like yeah, you don't do anything, and yeah, that's when it gets gets to kind of be bad.
• 58:32
  William Auten: Yeah, you gotta on um just about every claim, you've gotta hit the ground running because what seems to be fairly benign might blow up in your face, and it might blow up because you didn't do what you needed to do and get the information you needed to get.
• 58:49
  William Auten: Absolutely.
• 58:50
  Chantal Roberts: So we will be a fun one.
• 58:52
  Chantal Roberts: Yeah, we'll see you in two weeks.
• 58:55
  Chantal Roberts: Oh, be sure to like, subscribe.
• 58:57
  Chantal Roberts: I always forget to say this like, subscribe, blah, blah, blah.
• 59:00
  William Auten: Share with other people, share with other people, send us love.
• 59:04
  William Auten: Tell us if you want uh, show them your shirt.
• 59:06
  William Auten: We gotta, we gotta promote these shirts because if you want to boycott now, yeah, you've got bling.
• 59:11
  William Auten: We we need to set up a store, people can buy coffee mugs and and stuff like that, yeah, or Patreon or like whatever.
• 59:19
  Chantal Roberts: I don't know.
• 59:20
  Chantal Roberts: Um, all these all these web or all these podcasts I listen to, like become our special listener and Patreon.
• 59:27
  Chantal Roberts: And like I would love to have money, but I don't know.
• 59:30
  Chantal Roberts: It sounds like a lot of work.
• 59:32
  William Auten: Right.
• 59:33
  William Auten: Well, uh, we are um we are bootstrapping this operation.
• 59:38
  William Auten: Yeah, we are uh uh the we're trying to keep the costs low to bring you the the best quality uh that we can.
• 59:45
  William Auten: Um so if uh if anybody has a suggestion for improvements for this show, please let us know.
• 59:52
  Chantal Roberts: Please let us know.
• 59:53
  William Auten: And I will try to be the most energetic co-host I can be.
• 59:57
  Chantal Roberts: Okay.
• 59:58
  Chantal Roberts: See you in two weeks.
• 1:00:00
  William Auten: Yes, ma'am.
• 1:00:01
  Chantal Roberts: Bye.
• 1:00:02
  William Auten: Bye.
• 1:00:02
  William Auten: Thanks for joining us on the Art of Adjusting podcast, where we talk about life as an insurance adjuster.
• 1:00:07
  William Auten: Hit that subscribe button real quick and tell all of your adjuster friends to check this out as well.
• 1:00:12
  William Auten: For independent adjusting services, go to www.autin.claims.
• 1:00:17
  William Auten: And for anyone interested in working as an independent liability adjuster, go to the contact us tab to join our roster.
• 1:00:25
  Chantal Roberts: So this wraps up another Art of Adjusting podcast.
• 1:00:28
  Chantal Roberts: If you enjoyed this podcast or this episode, please give us five stars and a review.
• 1:00:34
  Chantal Roberts: It does help the algorithm pick us up.
• 1:00:37
  Chantal Roberts: In the meantime, you can contact me at theartofadjusting.com for consulting and training purposes.