March 2016 www.oregoncasualtyadjusters.org | PO Box 87 • Dexter, OR 97431 Claims Adjusters Association Oregon Providing informational and educational resources to the Insurance Claim Professional since 1935 OCAA scholarships for $500 each were awarded to Makayla Cohan (daughter of OCAA member Barb Cohan), and Brittany Nelson (daughter of OCAA Past President Tammi McEnaney). Makayla will attend the University of Oregon or Oregon State University with plans to be a physi- cian. Brittany plans on attending Concorde Univer- sity and studying to be a Certified Surgical Techni- cian. Our monthly raffle drawing at our luncheon meet- ings and the raffle held at the annual symposium is how we are able to provide these valuable scholar- ships to students. Thank you to everyone who pur- chases tickets throughout the year. Speaking of the symposium, the agenda and regis- tration form is included at the back of this issue. We are bringing back breakout sessions with two topics each session in order to provide more learning op- portunities for attendees. The best news is… OCAA members will not have to pay registration fees this year ! That’s correct, if your membership dues are current for 2015-16 you can attend the symposium for free! Adjusters and claim profes- sionals can join OCAA right now for the special rate of $25 so they also can gain entry to the sym- posium at no charge (there is a $35 symposium reg- istration fee for those not joining OCAA). PASS THE WORD!!! Note: some of you receiving this newsletter are NOT current in your dues at this time. Please check your membership status with our as- sistant Barb Tyler at [email protected]. Message from OCAA President Trevor Arnold, McLarens What Do Those Letters Mean? — Page 7 Welcome New Treasurer Judy Daufel Judy Daufel, of Norcross, is based out of their Portland office as a Casualty General Adjuster. Judy graduated from the Uni- versity of Oregon School of Journalism and holds an Associ- ate in Claims designation (AIC). For the past 37 years Judy has worked in the loss adjusting industry, with an emphasis in handling transportation claims regionally on the West Coast. She also has extensive experience in nearly all aspects of casualty work with special expertise in complex liability in- vestigations, multiple claimant, and catastrophic exposures. — Page 3 NEWS from Around the Web OCAA Spring Symposium Agenda & Registration — Pages 22 & 23 Rein In Bodily Injury Severities — Page 17 Getting Claim Costs Under Control — Page 20 Case Study Case Study — Page 11
Transcript
March 2016 www.oregoncasualtyadjusters.org | PO Box 87 • Dexter, OR 97431
Claims
Adjusters
Association
Oregon Providing
informational and educational resources to the
Insurance Claim Professional since 1935
OCAA scholarships for $500 each were awarded to Makayla Cohan (daughter of OCAA member Barb Cohan), and Brittany Nelson (daughter of OCAA Past President Tammi McEnaney).
Makayla will attend the University of Oregon or Oregon State University with plans to be a physi-cian. Brittany plans on attending Concorde Univer-sity and studying to be a Certified Surgical Techni-cian.
Our monthly raffle drawing at our luncheon meet-ings and the raffle held at the annual symposium is how we are able to provide these valuable scholar-ships to students. Thank you to everyone who pur-chases tickets throughout the year.
Speaking of the symposium, the agenda and regis-tration form is included at the back of this issue. We are bringing back breakout sessions with two topics each session in order to provide more learning op-portunities for attendees. The best news is… OCAA members will not have to pay registration fees this year! That’s correct, if your membership dues are current for 2015-16 you can attend the symposium for free! Adjusters and claim profes-sionals can join OCAA right now for the special rate of $25 so they also can gain entry to the sym-posium at no charge (there is a $35 symposium reg-istration fee for those not joining OCAA). PASS THE WORD!!!
Note: some of you receiving this newsletter are NOT current in your dues at this time. Please check your membership status with our as-sistant Barb Tyler at [email protected].
Message from OCAA President Trevor Arnold, McLarens
What Do Those Letters Mean? — Page 7
Welcome New Treasurer Judy Daufel Judy Daufel, of Norcross, is based out of their Portland office as a Casualty General Adjuster. Judy graduated from the Uni-versity of Oregon School of Journalism and holds an Associ-ate in Claims designation (AIC). For the past 37 years Judy has worked in the loss adjusting industry, with an emphasis in handling transportation claims regionally on the West Coast. She also has extensive experience in nearly all aspects of casualty work with special expertise in complex liability in-vestigations, multiple claimant, and catastrophic exposures.
— Page 3
NEWS from
Around the Web
OCAA Spring Symposium Agenda & Registration
— Pages 22 & 23
Rein In Bodily Injury Severities
— Page 17
Getting Claim Costs Under Control
— Page 20
Case Study
Case Study — Page 11
OCAA — March 2016 - 2 -
Time 11:30am to 1:00pm Location Old Spaghetti Factory 715 SW Bancroft St, PDX Menu Choices $15 Chicken Parmigana, Spinach & Cheese Ravioli, or BLT Salad Checks, cash or credit card accepted RSVP Requested www.oregoncasualtyadjusters.org
This newsletter is a publication of the Oregon Casualty Adjusters Association It is produced and distributed monthly by
OCAA Vital Statistics 2015-16 PO Box 87, Dexter, OR 97431 Website: www.oregoncasualtyadjusters.org Email: [email protected]
BOWLING PAST PREZ. TAMMI MCENANEY 503/736-8356 BUDGET & FINANCE COMMITTEE POSITION OPEN CONSTITUTION & BYLAWS PAST PRES. & CHAIR SPUNKY GRAY, 800/788-3933 PAST PRES. RON GRAY EMPLOYMENT SECRETARY POSITION OPEN GOLF PAST PRES. MARK JOHNSON, 503/565-2833 PAST PRES. MIKE MEADOWS, 503/565-3755
MEMBERSHIP PAST PRES. PATTY FERGUSON, 800/242-2923 X2551 MEETING PROGRAM & SPEAKERS PRESIDENT-ELECT POSITION OPEN
NEWSLETTER, SYMPOSIUM & WEBSITE COORDINATOR BARB TYLER, ALQUEMIE PUBLISHING 541/937-2611, [email protected] PARLIMENTARIAN PAST PRES. RON GRAY, 855/426-8898 SCHOLARSHIP SECRETARY POSITION OPEN SYMPOSIUM TREVOR ARNOLD, 503/505-7534
LEGISLATIVE LIAISON PAST PRES. SPUNKY GRAY, 800/788-3933
HOLIDAY PARTY PAST PRES. ERICA MCDANIEL 503/736-7185
FAIR USE NOTICE: This publication contains copyrighted material the use of which has not always been specifically authorized by the copyright owner. News and informational articles posted here are for
the non-profit purposes of education and news reporting. We believe this constitutes a 'fair use' of any such copyrighted material as provided for in 17 U.S.C § 107.
What does it take to be an officer of OCAA? Be-sides willingness and interest, it takes very little to make this association tick and remain in existence.
President: Leads the group, arranges for committee chairs, communicates by email, runs the monthly meetings, makes arrangements for the annual Past President’s dinner. If supported by a full slate of officers, time of involvement estimated to be about 1 hour per week, plus time at monthly meetings and events.
President-Elect: Stands in for the President when absent, schedules a speaker for each of the monthly luncheon meetings. If supported by a full slate of officers, time of involvement estimated to be about 1 hour per month or less, plus time at monthly meetings and the annual symposium.
Treasurer: Keeps the financial books in order, makes bank deposits, is in receipt of money at the monthly meetings, writes checks to pay OCAA bills. If supported by a full slate of officers, time of involvement estimated to be about 1 hour per month, plus travel, plus time at monthly meetings and the annual symposium. News Flash! This po-sition recently filled by Judy Daufel of Norcross!
Secretary: Takes the minutes of each monthly meeting, receives correspondence regarding em-ployment opportunities, and manages the Scholar-ship program. If supported by a full slate of offi-cers, time of involvement estimated to be less than 1 hour per month except during time of scholar-ship awards, plus time at monthly meetings.
All of the above are supported by...
The Executive Assistant: who manages dues re-newals and the membership roster, publishes the monthly newsletter, updates the website, manages new advertising and renewals, coordinates the an-nual symposium along with the committee chair, hosts our association’s mailing address and re-ceives all incoming mail, receives and disperses email from the website, takes phone calls, and more...
Please see the list of officers on page 2 and decide which open position is right for you and contact President Trevor Arnold to discuss. The Associa-tion was never meant to drive itself…
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NEWS from
Around the Web
Oregon: Open House to review updated FEMA maps is March 17 (c) 2016 Plus Media Solutions Private Limited
Washington County of Oregon has issued the following news release:
Updated Federal Emergency Management Agency (FEMA) Flood Insurance Rate maps will be available for public review at an open house from 6 to 8 p.m. March 17 at the Washington County Public Services Building, 155 N. First Avenue, Hills-boro.
Representatives from Washington County, FEMA, the state De-partment of Land Conservation and Development (DLCD) and consultant Amec Foster Wheeler will be available to answer questions. The event is hosted by Washington County Depart-ment of Land Use & Transportation.
Attendees will learn about the new digital flood plain maps, the primary regulatory tool used by the National Flood Insurance Program (NFIP) and the insurance industry to regulate flood-plain development and rates for flood insurance policies. The geo-spatially referenced digital maps will be used by federally regulated lending institutions and insurance agents to determine who must purchase flood insurance, and the cost of that insur-ance, if it's necessary. In addition, the maps will be used by county and city officials for floodplain management and permit-ting purposes.
If you need a sign language interpreter, assistive listening device or a language interpreter, please call 503-846-7800 (or 7-1-1 for Telecommunications Relay Service) at least 48 hours prior to this event.
Washington County is committed to working with our partner agencies in planning, building and maintaining a great transpor-tation system, ensuring the safety of all roadway users, and oper-ating the County roadway system in a cost-effective and envi-ronmentally responsible manner.
ODOT Posts New Speed Limits on Central and Eastern Oregon Highways
BEND - Motorists will see new speed limits on select highways in Eastern and Central Oregon as of Tuesday, March 1.
Oregon House Bill 3402 and HB 4047 (signed by the Governor in 2015 and earlier this month) raises speed limits on Interstate 84 east of The Dalles, I-82 and other select secondary state high-ways in eastern and central Oregon. The new law will raise legal speeds to 70 mph for passenger vehicles and 65 mph for com-mercial trucks on I-84 between the Idaho border and The Dalles
(See News… continued on page 5)
OCAA — March 2016
medical records as well. 3. Never suggest that you were attacked "randomly" as if this
horrible thing came your way simply out of the blue. The facts are that these hackers targeted the Hollywood Presby-terian Medical Center specifically because they knew their cyber-security defenses were weak or non-existent.
4. Never pay the ransom. Take the hit. Pay whatever you have to in order to re-create it all and button it up so it won't hap-pen again. Then, walk back everything you have said and come clean.
Mary Siero, an experienced CIO in healthcare, agrees that companies need to be better prepared for ransomware, which is increasing at an alarming rate.
"Organizations should not assume that the breach is minor without an in-depth assessment and should also not assume that sensitive data has not been breached until they have their assessment," says Siero. "Hopefully the organization has con-sidered the seriousness of these and other breaches and devel-oped an Incident Response Plan in advance of breaches."
"If you are in the healthcare space and are fortunate enough to have avoided a breach thus far, take a lesson from this event and start investing in your own cyber-defenses right now," says King. "I am sure you are on someone's list somewhere."
Investigation Opened Into Ford F-150 after Brake Failure Reports — by Christopher Jensen Reprinted from www.nytimes.com
Federal regulators are investigating reports of brake failure that may affect about 420,000 Ford F-150 pickup trucks. The National Highway Traffic Safety Administration said in a report on its website that it had received 33 consumer com-plaints, including reports of four crashes. The affected trucks are the F-150 with the 3.5 liter V6 engine from the 2013-14 model years. No injuries have been reported.
One owner from Saugus, Calif., wrote the agency last Septem-ber saying that the brakes failed while the truck was being driven in heavy traffic. “I was able to exit the freeway by down shifting and using the emergency brake,” the owner wrote. “I see I’m not the only person with this issue, yet noth-ing – as far as I can tell – is being done about it. Does some-one have to be injured or killed?”
If the agency finds additional cause for concern it would up-grade the investigation to an “engineering analysis,” which is more likely to result in a recall.
“The complaints allege symptoms of brake pedal going to the floor with complete loss of brake effectiveness, brake warning lamp illumination and/or low or empty master cylinder reser-voir fluid level with no visible leakage,” the report said. “Several complaints allege repair facilities diagnosed the problem as brake fluid leaking from the master cylinder to the brake booster.”
John Cangany, a Ford spokesman, wrote in an email that the automaker took “the safety of our customers very seriously and we will cooperate with N.H.T.S.A.”
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and on I-82 between I-84 and the Washington border. These same speed limits will apply for U.S. 95 which runs through southern Malheur County between the Nevada and Idaho bor-ders.
In addition, sections of eight other highways will have speed limits increased to 65 mph for passenger vehicles and 60 mph for trucks. These include portions of U.S. 20, U.S. 26, U.S. 97, U.S. 197, U.S. 395, OR 31, OR 78, and OR 205.
ODOT Director Matt Garrett had this to say about the new speed limits. "The transportation professionals in our Highway Division employed engineering disciplines and innovative methods to make sure we complied with the Legislature's intent in a cost-effective manner, while ensuring we striped and signed affected highways and freeways in a way that promotes safety for the traveling public."
Signs displaying the new speed limits are expected to be in-stalled on I-84 by March 1 and on secondary highways within a few days of the March 1 effective date. Motorists are reminded to obey all speed limit signs and other traffic control devices, and to adjust travel when weather, road conditions or other situations require extra caution.
Those signs displaying a speed "limit" will be subject to en-forcement by the Oregon State Police as differentiated from the "basic speed rule" that applies when no "limit" is indicated.
The healthcare industry suffered another blow when the Holly-wood Presbyterian Medical Center in Los Angeles was hit by a devastating cyberattack that crippled its operations and put patients' lives at risk in a breach called a "ransomware," be-cause the attackers are demanding $3.6 million to restore its computer systems and networks.
The hospital's CEO, Allen Stefanek, responded by saying that the attack appeared to be random and that no patient or em-ployee information was at risk.
According to one of the country's leading cyberattack experts, Steve King, chief security officer for Netswitch Technology Management, Stefanek's response was inadequate at best and possibly dangerous.
King said there are four things never to do in case of a breach of this magnitude.
1. Never wait to acknowledge a breach. The longer you delay, the more it looks like you have something to hide and the less your customers will trust you.
2. Never insult the public's intelligence by saying that "no pa-tient or employee information is at risk" when it is obvious that if the attackers were clever enough to lock down the hospital's systems, they are certainly capable of stealing the
News… (Continued from page 3)
OCAA — March 2016
The insurance industry values the education — and on-going education — of its professionals.
Throughout the country, agents must be licensed in each state, and many states require adjusters to be licensed as well. This licensing ensures that the fun-damentals are understood and can be applied.
But it doesn’t stop there. The professional agent, adjuster, underwriter or loss control specialist real-izes how beneficial advanced education is for one’s understanding of the industry, and the ability to hone one’s skills in applying that knowledge.
There are many organizations providing such edu-cation. Education is so valued within the industry that most companies will pay for classes, texts and exams in order to support employees in their ca-reers. Some may even give bonuses for passing classes.
And the most visible reward for this specialized knowledge? The right to use professional designa-tions after a person’s name.
To an insurance outsider — and to a novice in the profession — the alphabet soup that often appears after a person’s name is mystifying. So here’s a primer on what those post-nominal designations mean, and which entity grants them:
PLCS, CLCS and SBCS The Erlanger, Ky.-based National Underwriter Co. offers three insurance designations.
— Personal Lines Coverage Specialist, PLCS. De-signed for new and experienced professionals alike, it provides solid foundational and specialized knowledge necessary to understand personal lines coverages starting with insurance principles and explaining in depth homeowners, auto, and um-brella coverages. This is the only designation avail-able dealing with personal lines to such an extent. Six e-learning courses are provided allowing the student to fully master complex content. An in-depth knowledge of this information is key for any-
(See Designations… continued on page 8)
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Helping You Solve The Puzzle
Ready to assist you now with: • Structural Evaluation • Origin & Cause Fire Investigation • Accident Reconstruction • Construction Defect Investigation • Vehicle Component Failure • Product Safety Analysis • Electrical Analysis and Evaluation
What Do Those Letters Mean? A Look at Professional Designations By Christine G. Barlow, CPCU Reprinted from www.propertycasualty360.com
OCAA — March 2016 - 8 -
one hoping to specialize in personal lines. The con-tent is written by editors of FC&S Bulletins, well-respected providers of insurance policy interpreta-tion for over 80 years. Continuing education credits are available.
— Commercial Lines Coverage Specialist, CLCS. This is designed to give expert knowledge of the fundamental commercial lines of coverage: general liability, commercial property, workers compensa-tion, business auto, as well as insurance principles. The coverage guides give complete analysis of commonly used coverage forms. As with PLCS, content is written by the editors of FC&S Bulletins, and continuing education credits are available.
— Small Business Coverage Specialist, SBCS. This is the only designation of its kind. It focuses on the particular coverage needs of small businesses and how to provide them using common policy forms. It combines personal lines and commercial lines forms, because small businesses may be home-based or could need commercial coverage. This designation explains when to use which type of coverage, and is also written by the editors of FC&S Bulletins with continuing education credits are available.
CPCU The Malvern, Pa.-based American Institute for Chartered Property Casualty Underwriters is a large organization that provides classes for a variety of designations; some may simply be certificate classes, while others confer a designation. All are geared towards the property and casualty side of the industry.
The most well-known and respected designation it grants is the Chartered Property Casualty Under-writer, CPCU.
The designation consists of four foundation courses, three courses from either the personal lines or com-mercial lines concentration, one elective and one ethics course. The foundational courses cover ba-sics in the industry of risk management, accounting, insurance operations and law. The concentrated courses provide basics in personal or commercial lines. Continuing education credits are available.
CIC The Austin, Texas-based National Alliance for In-
Designations… (Continued from page 7)
OCAA — March 2016
clude income taxes, group benefits, retirement plan-ning and health insurance. Continuing education credits are required in order to maintain the desig-nation. The ChFC requires nine classes which in-clude financial planning, income taxation, invest-ments, estate and retirement planning plus electives.
CFE Fraud is such an issue within the industry that there are designations for those dealing with fraud. The Austin, Texas-based Association of Certified Fraud Examiners has a Certified Fraud Examiner, CFE designation. Not specific to insurance, the designa-tion course covers financial transactions and fraud schemes, law, investigation, and fraud prevention and deterrence. As always, an exam is required.
AHFI The Washington, D.C.-based National Health Care Anti-Fraud Association has the Accredited Health-care Fraud Investigator, AHFI designation. Re-quirements include 75 hours of training or teaching on healthcare fraud and passing the required exam. An Investigator’s Boot Camp is available for train-ing.
(See Designations… continued on page 11)
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surance Education & Research has a number of des-ignations as well, most notably the Certified Insur-ance Counselor, CIC.
Again, core courses are required in order to obtain the designation, including personal and commercial lines, life and health, and agency management. In order to maintain the designation, one of a variety of programs must be attended annually. Again, solid foundational knowledge is provided for key elements of insurance coverage, using the ISO forms. Life and health designations are available as well.
CLU and ChFC The Bryn Mawr, Pa.-based American College of Financial Services has a number of designations dealing with the life and health and financial advi-sor sectors of the industry.
Chartered Life Underwriter, CLU and Chartered Financial Consultant, ChFC are two of its well-known designations. Eight classes are required for the CLU covering insurance and financial planning, life insurance law, estate planning and business owners and professionals planning. Electives in-
OCAA — March 2016
From the desk of Katie D. Buxman: Can a medi-cal expert testify about emotional overlay? Can a biomechanical expert testify about the effect of crash speeds on the human body? Find out in this follow-up to last month’s update on an important Oregon Court of Appeals opinion.
Claims Pointer: The Court of Appeals ruled in the following case that a biomechanical expert may tes-tify regarding the forces of an auto accident and the tolerance for the human body to sustain such forces. The Court also held that a medical expert could tes-tify regarding a plaintiff’s emotional overlay
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Fact Finding Through Forensics
To submit an article to this publication contact Barb Tyler at [email protected] or 541/937-2611.
Who Can Testify About What In Low-Impact Auto Accident Cases? By Katie D. Buxman
Case Study
RF For risk management professionals, RIMS has the RIMS Fellow, RF designation. This requires com-pletion of three college-level courses in risk man-agement or earning one of the following designa-tions: ARM Association in Risk Management, CRM Canadian Risk Management, CRM Certified Risk Manager, and ALARYS AIRM. Also required is five years’ experience in the industry, four courses in business acumen, attendance at 12 days of RIMS Fellow workshops or equivalent online courses. In order to maintain the designation, cred-its must be obtained by attending two days of RIMS Fellow workshops and certain professional activity, such as speaking, teaching, publishing articles or attending conferences and seminars.
Designations… (Continued from page 9)
OCAA — March 2016 - 13 -
(emotionally or psychologically-created pain) where there was no anatomical cause or source of the plaintiff’s pain.
Thoens v. Safeco Insurance Co. of Oregon, 272 Or App 512 (July 22, 2015)
Susann Thoens (Thoens) was injured in an auto ac-cident while stopped behind a school bus. The re-sponsible driver was traveling at a rate of 5 to 10 mph. Thoens received medical treatments for head-aches, neck pain, pain in her right arm, blurred vi-sion, and balance problems. Thoens was treated by a chiropractor, who was also her husband and em-ployer. Thoens also treated with a number of physi-cians and received surgery on four levels of her cer-vical spine. By the time of trial, Thoens’ medical bills totaled more than $200,000.
As discussed in last week’s update, Thoens’ insurer, Safeco Insurance Co. of Oregon (Safeco), cut off personal injury (PIP) benefit payments and denied underinsured motorist (UIM) coverage after an in-dependent medical examination (IME) revealed that Thoens’ injuries were not caused by her accident.
Thoens brought claims against Safeco for denying PIP benefits and UIM benefits after settling with the underinsured driver. Prior to trial, Thoens moved to exclude “any biomechanical testimony.”
Thoens renewed that motion when Safeco called its biomechanical expert, Bradley Prost, to testify. Thoens argued that Probst’s methods were “essentially based on junk science” and that Probst lacked the credentials to testify. During a hearing to determine whether Probst could testify as to whether the accident could have caused Thoens’
Case Study… (Continued from page 11)
(See Case Study… continued on page 14)
OCAA — March 2016 - 14 -
injuries, Probst listed an impressive resume and provided his methodology, which relied on a num-ber of peer-reviewed studies. The trial court over-ruled Thoens’ motion and allowed Probst to testify. Probst’s ultimate conclusion was that there was no “causal relationship” between Thoens’ injuries and the accident.
Thoens also made a motion to exclude any evidence or testimony that she was not credible. The trial court granted the motion. During Safeco’s presenta-tion of evidence, it called a medical expert, Dr. Scott Jones, an orthopedic surgeon, to testify re-garding Thoens’ treatment. Dr. Jones testified that Thoens’ surgery was not reasonable based on his review of Thoens’ medical records, the circum-stances of the accident, and the testimony of Thoens’ surgeon. Among the reasons he listed for his conclusion was that Thoens’ presentation “had emotional components displayed, which are red flags and a bit disturbing.”
While the jury was deliberating, they sent a written question to the judge, which asked Dr. Jones to ex-plain what the emotional overlay was and why it was a “red flag.” The judge asked Dr. Jones to an-swer, but warned him to avoid the words “malingering” and “somatoform disorder” because they commented on credibility. Dr. Jones then testi-fied that Thoens’ description of the accident was “dramatized” and that her description of symptoms was anatomically impossible as a result of the acci-dent. He assessed that in his experience, patients’ emotions often drive their symptoms, but that Thoens’ presentation was especially concerning and more pronounced than others. Thoens objected to the testimony, but the trial court allowed it.
Thoens appealed both of these issues after the jury gave a verdict in favor of Safeco on her UIM claim. The Oregon Court of Appeals ruled that the trial court did not make a mistake by allowing Probst, Safeco’s biomechanical expert, to testify. First, Thoens challenged Probst’s methodology, arguing that Probst could not accurately calculate the speed of the car that struck Thoen’s vehicle based on pho-tos and a description of the accident. The Court held that Probst’s method was acceptable and was supported by the evidence.
Case Study… (Continued from page 13)
OCAA — March 2016 - 15 -
Thoen’s main argument was that Probst’s method for determining the tolerance of human tissue to sustain certain forces was flawed. The Court ob-served that Thoens pointed out significant flaws in Probst’s methodology and the studies that he relied on, but nonetheless held that under Oregon law, those issues spoke to the weight, not the admissibil-ity, of his testimony. Because Thoens could not es-tablish that Probst’s testimony lacked scientific sup-port, Probst was properly permitted to testify. Moreover, the Court pointed out that other experts, including some of Thoens’ experts, made findings similar to Probst that based on the nature of the ac-cident, Thoens’ injuries could not have been caused by the 5-10 mph collision.
Second, the Court observed that Probst had signifi-cant credentials that qualified him to testify regard-ing human tissue thresholds including: that he had a Ph.D. in biomedical engineering, worked with the Office of Naval Research in developing a computer model of the human head and cervical spine in or-der to analyze automobile accidents, conducted ap-proximately 100 auto crash tests, investigated nearly a thousand different auto-related injuries, and testified in 14 states, including Oregon. The Court rejected Thoens’ argument that Probst re-quired a medical degree to testify regarding injury thresholds. The Court pointed out that Probst’s tes-timony was based on structural limitations of hu-man tissue, not medical treatment or causation, so a medical degree was unnecessary.
The Court also rejected Thoens’ argument that Dr. Jones’ testimony regarding “emotional overlay” commented on Thoens’ credibility. The Court ob-served that Dr. Jones did not testify that Thoens was “faking” or exaggerating her injuries. He only stated that in his opinion, Thoens’ perceived pain was psychological and emotional instead of physio-logical or anatomical because there was no identifi-able physical cause of her injuries.
— View the full case opinion at: www.publications.ojd.state.or.us/docs/A150983.pdf
— If you would like to be notified of these new cases, please send an email to: [email protected]. This article is to inform our clients and others about legal matters of current interest. It is not intended as legal advice. Readers should not act upon this information without seeking professional counsel.
OCAA — March 2016
It is no secret that bodily injury severities continue to rise significantly faster than the rate of inflation.
Compounding the problem is that frequency is ris-ing as well. Prior to 2015, the industry had taken note of the rising bodily injury (BI) indemnity costs, but took some solace in the declining fre-quency. With cars becoming safer, these divergent trends made sense in that there should be fewer in-jury claims, but those that were reported tended to be more serious, hence the rise in the average paid. All of that changed last year when both severities and frequency rose. Now insurers are faced with the increased challenge of being able to properly price for this double whammy.
The good news is that there are steps that can be taken to combat this rise. The bad news is that it requires the full attention of management who must effectively deliver consistency from all front line adjusters in order to get accurate settlements.
Consider a typical scenario. It’s been two years since the date of loss and the plaintiff attorney has been remiss at returning phone calls and responding to letters, and is basically ignoring any e-mails. Suddenly, a large demand lands on your desk with nearly $20,000 in medical bills!
The adjuster is puzzled because there was virtually no damage to either vehicle. However, the bills have been incurred and many adjusters will simply consider them at face value. While the bills may be questionable, attorneys are quick to point out that they will be able to black board the full value in many jurisdictions.
The proper rebuttal is to focus on the facts of the case, including both causation of injury and neces-sity of treatment. While attorneys may ultimately choose to litigate the case, this is a costly proposi-tion for a highly improbable outcome. Carriers de-fending such cases have a wide array of tools in their arsenal to fight such runaway costs including bill review software, medical coding experts and independent medical examination doctors who will
(See 12 Keys… continued on page 18)
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12 Keys to Rein in Bodily Injury Severities By Christopher Tidball Reprinted from www.propertycasualty360.com
OCAA — March 2016 - 18 -
refute many, perhaps even all, aspects of the plain-tiff’s claim.
The reality is that most claims do not go into litiga-tion, let alone reach the courtroom. Plaintiff attor-neys generally understand the limitations of their cases, just as adjusters do.
There are also a number of steps adjusters can take to proactively position a case for a settlement that is fair and just. Here are 12 steps to an accurate bodily injury outcome:
1. Police report While generally considered to be inadmissible in court, this document can be a treasure trove of in-formation that will assist with the investigation.
Was there any mention of an injury at the scene? Was the injured party transported to a medical facil-ity? Was there any mention of contributing factors against the claimant? Were any witnesses identi-fied? Did the police respond, or was a counter re-port filed after the fact?
2. Liability Who is at fault for the accident?
Insurance adjusters across the industry assess com-parative negligence on just 3% to 5% of all claims, a vast understatement of what should truly be as-sessed.
In looking at claims that are adjudicated, Jury Ver-dict Reporter has indicated that more than half of all claims involve facts pointing to shared liability.
Using tools such as ClaimIQ can provide adjusters with the critical elements needed to properly iden-tify duties owed and breached.
3. Vehicle photographs (auto claims) Does the damage match? Are there paint transfers? A white car hitting a blue car will not leave a red paint transfer.
What is the directional force of impact? Is the dam-age such that the injury being claimed may be re-lated?
Was there a mechanism for injury? For example, a lumbar injury in a sideswipe collision is highly im-probable.
12 Keys… (Continued from page 17)
OCAA — March 2016
In addition, point of impact plays a significant role in the assessment of comparative fault.
4. The accident scene Are there any other potential tortfeasors?
Overgrown bushes, signal outages, missing or blocked signage, absentee third parties and similar factors should always be investigated.
Does the movement, as stated by the parties, corre-spond to what is being visualized?
5. Emergency room records What was said to the emergency medical techni-cians at the scene and during transport? What does the ER admission statement say?
What type of pain was related to the treating physi-cian? Was there a mention of symptoms other than what may be related to the accident?
Is there any indication of drug or alcohol usage that may have contributed to the loss? Is there any indi-cation of pre-existing conditions?
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6. Medical treatment patterns How soon did treatment begin? Were there gaps in treatment?
Was treatment provided on evenings and/or week-ends? Were you able to verify treating physician office hours?
7. Provider type Was the claimant seen by a chiropractor or medical doctor? If the latter, then what was his or her spe-cialty, such as neurology, orthopedics and so on?
What are the medical professional’s credentials? Is his or her licensure current? Are there any prior or pending disciplinary actions with the current or prior states? Can the claimant describe the doctor, medical facility and staff, and provide directions from home and/or work to the facility?
8. Medical costs, duration and frequency of treatment When did treatment start? How long did it last? Was it active or passive?
Was it longer than an anticipated expected recovery date among the general population for a similar complaint?
Was a bill review tool used to price medical bills based upon proper jurisdictional benchmarks? Were there deceptive billing practices such as upcoding, unbundling or modifier abuse?
9. Objectivity Were there objective findings such as an X-ray, MRI or CT scan?
Were the records and films obtained and reviewed by an independent medical expert?
Was there any evidence of trauma or were the ob-jective findings pre-existing?
10. Pain management Did the doctor prescribe medication to ease the complaints of pain?
If so, then what type (analgesics, prescriptions, in-jections)?
Was the use excessive? Were opioids involved?
(See 12 Keys… continued on page 20)
OCAA — March 2016
The property/casualty industry is undergoing sig-nificant challenges with increased claim severity in liability and physical damage claims. These in-creases are outpacing inflation and rate adequacy. According to the Insurance Information Institute, in 2009 the average private passenger auto bodily in-jury claim was $13,891. In 2014, that average grew to $16,640 – an increase of almost 20 percent. The private passenger auto collision loss ratio has risen from 67.7 percent in 2010 to 78.3 percent in 2015 – a 16 percent increase. The loss ratio can be ad-versely impacted by claim handling, underwriting and rate inadequacy with claim leakage as a pri-mary cause of loss ratio deterioration.
Although the severity trend is indeed a challenge, the good news is a quality-driven claim organiza-tion can take action to do something about it.
Back to Basics A quality-driven claim organization can improve the loss ratio by up to 4 points by getting back to basics – in other words, focusing on best practice technical and supervisory tactics which have a di-rect or indirect impact on the loss ratio. These tac-tics include applying fundamental claim skills in investigation, evaluation and negotiations including comparative negligence; staffing and workload management; and implementing comprehensive quality review processes.
Fundamental Claim Skills & Comparative Negli-gence Placing too much emphasis on closure ratios can lead to overpayment of claims, thus increased se-verity. Claim personnel must be thoroughly trained and be effective in liability and damage evaluation to properly evaluate bodily injury claims – under-standing both objective (medical & wage claims) and subjective (pain & suffering) components in the evaluation process.
11. 'SOAP' notes Does the treatment being provided and billed match the medical provider's SOAP (subjective, objective, assessment plan) notes, which can be a great indica-tor of not only what treatment really occurred, but also a red flag for current procedural terminology coding and modifier abuse.
12. Index and priors Did the claimant have prior claims or injuries? There is a percentage of the population that will abuse the system in an attempt to get compensated for every malady.
Adjusters need to do a detailed investigation, in-cluding seeking out prior providers, reviewing prior indexes, requesting medical authorization and re-viewing old claims. This can be time-consuming, but so is panning for gold. Digging deep during in-vestigations is not only a requirement of the job, but it is part of the duty of being a fiduciary for the in-sured in order to pay only what is owed.
While there may be many additional steps, depend-ing on the type and complexity of the investigation, these 12 are designed to provide a roadmap for suc-cess. By focusing on the basic fundamentals, lever-aging the triad of people, processes and the right technology, insurers will find that they can effec-tively combat the rise in BI severities.
12 Keys… (Continued from page 19)
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Getting Claim Costs Under Control: Improve Your Loss Ratio Using These Proven Fundamentals By Michael T. Murdock, CPCU, ARM Reprinted from www.claimsjournal.com
OCAA Meeting Minutes of February 9, 2016 There were 16 in attendance. No Past Presidents or guests in attendance. Associate board member Melody Ewers conducted the meeting in the President’s absence. Treasurer’s Report: $15,176.35 in the General Account. $29 in Scholarship. Committee Reports: Symposium is April 28, 2016 at the Holi-day Inn in Wilsonville. More info coming soon.
Unfinished Business: None.
New Business: None. Speaker: Brandon W. Stuber with Davis Rothwell et el spoke on Cyber Liability Issues and Oregon’s Identity Theft Protection Act.
There was no Scholarship raffle. No one won the membership drawing. Pot grows to $200 for the March meeting.
Minutes submitted by Melody Ewers.
OCAA — March 2016 - 21 -
Get a Friend or Co-Worker to Join OCAA Today! We extend membership to anyone involved in the resolution of an insurance claim!
Membership includes: FREE admittance to the
Spring Symposium on April 28, 2016!
Go to: www.oregoncasualtyadjusters.org/
symposium2016.html
Understanding the impact of Comparative Negli-gence and applying it properly to liability claims (BI & PD) at the evaluation stage will improve re-sults – reserves, authority reviews and dispositions. There are three negligence doctrines which vary by state: Pure Comparative, Modified Comparative and Contributory Negligence – these doctrines indi-cate recovery for damages will be reduced by the percentage of fault attributable to each party. Under the Pure Comparative rule, a party can collect for damages even if they are 99 percent at fault. Most states have adopted the Modified Comparative rule which has two variations: the 50 percent rule and the 51 percent rule – meaning if you are 50 percent or 51 percent negligent you will be barred from re-covery. With the Contributory Negligence rule, in-jured parties may not collect damages if they are only 1 percent responsible for the accident.
We find that adjusters working in various jurisdic-tions are not always applying comparative negli-gence properly. Appropriately applying 15 to 20 percent of negligence on the adverse party will im-pact the loss ratio (for example, an insured making a left turn in front of the adverse vehicle) versus paying 100 percent to avoid confrontation with the claimant. If the adverse party is over 51 percent li-able for the accident in a modified comparative negligence jurisdiction, the claim should be denied. If the adverse party is liable for the accident in a contributory negligence jurisdiction, a claim denial may be in order.
Staffing & Workload Management There is a direct correlation with adjuster workloads and positive claim outcomes. The higher the work-load, the less time to conduct proper claim investi-gations (e.g., statements and photos), prepare qual-ity damage appraisals, evaluate and negotiate claims effectively, provide good customer service and properly manage reserves. A best practice is to conduct quarterly staffing analyses to evaluate workloads and trends. The best claim organizations have manageable caseloads with established work-load ranges for claim personnel by exposures (not claim files).
Span of control has a significant impact on a claim supervisor or manager’s ability to provide substan-tive and high-quality claim supervision. If the span of control is higher than six adjusters to one super-visor, quality is likely to suffer.
Quality Review & Re-inspection Programs Claim organizations require an effective claim audit process to properly evaluate claim trends at the ad-juster, claim unit, office and company level. A com-prehensive Quality Claim Review (Audit) Program using best practice categories (e.g., Contacts, Cov-erage, Investigation, Documentation, Evaluation, Disposition, File Development, Litigation Manage-ment, Expense Control, Recovery and Supervision) should be a core function in every claim operation. The process should be supported by technology and be able to trend data at a very granular level using intuitive analytical tools. This data can then be used as a basis for training and development.
An effective Re-inspection Program for auto physi-cal damage and property damage claims is essential to manage Auto Property Damage/Property Dam-age (and rental) costs. It doesn’t take much of a dol-lar impact per claim to deteriorate a loss ratio.
Take Action We recommend conducting an objective review of your claim organization to evaluate areas for im-provement. Consider rating your claim organization in the following areas:
Best practice claims handling and supervision; Liability and damage evaluation; Applying comparative negligence; Workload and span of control; Audit and re-inspection; Training.
You will find opportunities to reverse the increased severity trend by optimizing these important funda-mentals in your organization.
OCAA — March 2016 - 22 -
7:00 – 8:15 AM REGISTRATION & CONTINENTAL BREAKFAST 8:15 – 8:30 AM WELCOME & INTRODUCTIONS 8:30 – 9:30 AM GENERAL SESSION: The Future Was Yesterday (Candlewood / Redwood Room) Tom Underbrink, Director of Litigation - Mutual of Enumclaw
Tom Underbrink could never run for political office because he calls things exactly how he sees them. What he has to say about the current state and future possibilities within the insurance industry in general and the claims profession in particular will astound you. Tom will address the consequences of transformative technologies, global competition, economic and environmental uncertainties, changing consumer expectations, and a myriad of other mind-blowing paradigm shifts. Yes, if you ask, he’ll be happy to also talk about how virtual reality and drones will change adjusting forever… or maybe not.
9:30 – 10:30 am GENERAL SESSION: Hot Topics / Legal Update — “Let’s Kill All the Lawyers” (Candlewood / Redwood Room) Elizabeth Lampson of Davis Rothwell Earle & Xóchiua
In William Shakespeare’ Henry VI it is written, “First thing we do, let’s kill all the lawyers.” As a claims-handling strategy this probably isn’t considered a “best practice”, so your best alternative is to pay close attention during these Hot Topic-Legal Updates. Ignorance of the law is no excuse. Insurance claims are heavily regulated, rigorously legislated, and constantly litigated. As claims professionals we are directly impacted by new laws, judicial interpretation of those new laws, and ongoing legal battles over the interpretation and enforcement of existing laws.
10:30 – 11:00 AM BREAK & NETWORKING 11:00 – 12:00 PM BREAKOUT SESSION (Select one of two topics) 1) “The Truth Is Out There”– X-cellent Statement Taking (Cottonwood Room) Dale Bowman of Norcross
Inexperienced attorneys are taught early on that “You can’t WIN a deposition.” That same advice should be given to adjusters tasked with taking a recorded statement. We don’t know what we don’t know, and witness statements often unlock the mysteries of a claim. We just don’t know which witness, which statement, and/or which question is the key to pulling it all together. Dale Bowman will teach you the what, why, when, where, and how of taking statements.
2) Repairing Damage to Buildings: Upgrades Required or Desired (Dogwood Room) Zeno Martin of Wiss Janney Elstner Associates
If building codes are so simple and obvious, how come no two (insert name of claimant, contractor, architect, engineer, and/or building inspector here) interpret the laws and ordinances regarding building construction the same way? The confusion is made worse by a general misunderstanding of the Existing Building Code (which generally applies to insurance repairs). What can adjusters reasonably expect to be provided by the restoration contractor, architect, engineer, and/or governmental agency as confirmation and documentation of building code enforcement? Zeno Martin is a leading thinker in building codes, and claims professionals need to be armed with the right information.
12:00 – 1:00 PM LUNCH & NETWORKING 1:00 – 2:00 PM BREAKOUT SESSION (Select one of two topics) 1) AARP: Advanced Accident Reconstruction Professionals (Cottonwood Room) Patrick Riedlinger of Rimkus
We all know that eyewitness accounts aren’t always accurate (sometimes not even truthful), so there has to be a better way to figure out what happened and why. Enter Patrick Riedlinger of Rimkus to explain how collisions are reconstructed in a way that provides accurate, credible, and (hopefully) irrefutable evidence about the circumstances of your claim. Taking good statements is important (You WERE paying attention during the 11:00am “The Truth Is Out There” session, weren’t you?), but nothing beats Advanced Accident Reconstruction for separating fact from fiction.
2) When Good Adjusters Get Set-Up for Bad Faith (Dogwood Room) Dan Thenell of Thenell Law Group
Good intentions don’t necessarily prevent allegations of bad faith. Dan Thenell, SIU attorney extraordinaire, will walk us through the steps for investigating a claim, determining a reasonable loss, damage, and valuation, and negotiating a claim settlement without getting sued for bad faith. Spoiler alert, Dan’s solution does NOT include “holding the claimant to their demand”. We will learn the pitfalls, traps, and common mistakes that turn a mundane claim into a nightmare of accusations. We will also learn how an SIU investigation gets hijacked by the claimant’s recriminations. J’accuse, adjuster!
Oregon Casualty Adjusters Association
April 28, 2016 OCAA Spring Symposium & Vendor Fair About the OCAA Annual Spring Symposium & Vendor Fair
The 2016 OCAA Spring Symposium will honor the memory of Richard “Dick” Younge, OCAA Past President (1976-77) who passed away in December 2015. Dick was instrumental in starting the very first symposium as a way to avoid mandatory CE credits for adjusters that would have otherwise been imposed by the Insurance Division. The Symposium is designed to provide Claim Professionals with information that will broaden their knowledge base and help improve claim handling skills. This year we are bringing back breakout sessions in addition to the general ses-sion in the morning. This allows us to provide even more educational topics. As always, topics are presented by knowledgeable and talented speakers. See the Agenda below.
OCAA — March 2016 - 23 -
2:00 – 2:30 PM BREAK & NETWORKING 2:30 – 3:30 PM BREAKOUT SESSION (Select one of two topics) 1) I Didn’t Know It Was Plugged In- Electrical Effects & Investigation (Cottonwood Room) Adam Farnham of Unified Investigations & Sciences
Ever since Benjamin Franklin flew his kite into a lightning storm with a metal key dangling, claims professionals have had to deal with the after-effects of electrical currency. It’s shocking how little we know. Adam Farnham at Unified Investigations will hardwire our knowledge base about electricity, the effects of electricity, and investigative tips in how to determine what happened, why it happened, and whether or not we get to subrogate… or, worse, someone else gets to subrogate against us. There is no truth to the rumor that Adam plans to surreptitiously wire each chair to keep attendees alert and awake.
2) Show Me the Money!! Business Income & Extra Expense Claims (Dogwood Room) Katharyn Thompson, CPA with RGL Forensic Accountants; Karen Tallman, General Adjuster with Vericlaim; and Charlie Strube, Claims Manager at Country Financial
The learning objectives of this session are: Review techniques for building rapport with the insured and its representatives in order to facilitate the claims handling process; the role that effective communication plays in the handling of Business Income and Extra Expense claims; a guide to the top ten objectives or considerations that are critical to the successful adjustment of these time element claims; specific examples of challenges that may arise in the handling of these types of claims and explore creative ways to resolve them — this includes creative application of the techniques and communication skills examined.
Registration required for all attendees ~ includes lunch, snacks, and closing reception ~ Please check the appropriate box and fill out the remaining portion below ~
FREE Symposium attendance for OCAA Members I am a MEMBER of OCAA
Check your membership status by sending an email to [email protected] I want to be a member of OCAA to attend the Symposium for Free!
I’m paying $25 for dues* (OCAA membership good through July 2017)
$35 NON-MEMBER Symposium Registration *Membership is open to Adjusters (all lines), Claims Supervisors/Managers, and claim adjusting support staff.
Non-Member Symposium Registration Fees are nonrefundable after April 25, 2016 but are transferable to another person.
. . . Please print legibly . . .
Name Company
Claims Discipline: Property Casualty Auto Workers Comp Liability Other
Lunch Choice: Chicken Fish Vegetarian I’m signing up for membership in OCAA: Yes No
First time attending an OCAA Symposium? Yes No Attending Closing Reception: Yes No
Address City, State, Zip
Phone Email I would like an email confirmation that my membership/registration has been received.
Amount Enclosed:
$_______
April 28, 2016 Spring Symposium PRE-REGISTRATION
Holiday Inn Select 25425 SW 95th Ave Wilsonville, Oregon
