AIC 300 All Sections Flashcards

What is data mining?

Finding patterns and relationships in large data sets.

What is a case reserve?

An estimate of the expected future cost of a claim.

What is liability?

Legal responsibility for a loss.

What is good-faith claim handling?

Handling claims fairly, honestly, promptly, and reasonably.

What is the primary goal of settlement negotiations?

To reach a fair and reasonable resolution.

What is a KPI?

A Key Performance Indicator used to measure performance.

What does predictive analytics do?

Uses historical data to predict future outcomes.

What is a fraud red flag?

A suspicious circumstance suggesting additional investigation is needed.

What is the purpose of an initial claim assessment?

To determine how the claim should be handled.

What is the purpose of discovery?

To exchange information between parties in litigation.

What is claim severity?

The cost or financial impact of a claim.

What is a bona fide dispute?

A reasonable disagreement regarding coverage or claim value.

What is the primary mission of the claims function?

To provide fair and timely claim resolution.

What is classification tree analysis?

A method for sorting data into categories to support decisions.

What does documentation do for a claim file?

Supports and explains claim decisions.

What happens when litigation begins?

A lawsuit is filed.

What is an adjuster's role when fraud is suspected?

Gather facts objectively and investigate.

What should claim decisions be based on?

Facts, policy language, law, and ethics.

What is claim cycle time?

The time required to close a claim.

What is a deposition?

Sworn testimony taken before trial.

Why are witness interviews important?

They help gather facts about the loss.

What is claim value?

The financial value assigned to a claim.

What does a classification tree organize?

Information into decision categories.

What is professional ethics?

Standards guiding fair and responsible conduct.

What is an outlier?

A result that differs significantly from normal patterns.

What is the purpose of reserves?

To estimate future claim costs.

What is the first step in investigating a claim?

Gathering relevant facts.

What strengthens an adjuster's credibility during negotiation?

Accurate information and preparation.

What is claimant fraud?

Intentional misrepresentation by a claimant for financial gain.

What is objectivity?

Evaluating facts without bias.

What is the purpose of data experts?

To help interpret and analyze complex data.

What does a dashboard do?

Displays important information visually.

What is comparative negligence?

Shared responsibility for a loss.

What is evidence?

Information used to support claim decisions.

What is one strong defense against bad-faith allegations?

Proper documentation.

Why should reserves be updated?

Because claim facts change over time.

What is mediation?

A voluntary dispute-resolution process.

What is provider fraud?

Fraud involving healthcare providers or billing practices.

What does data quality affect?

The quality of decisions made from the data.

What is the purpose of interviewing claimants?

To obtain facts about the loss.

What is cause of loss?

The event that resulted in damage or injury.

What is integrity?

Adhering to ethical principles and honesty.

What does data mining identify?

Patterns and trends.

What is an interrogatory?

A written question requiring a written answer.

What is the purpose of collaboration with underwriting?

To share claim trends and risk information.

What is investigation?

The process of gathering and evaluating facts.

What does a fraud indicator prove?

Nothing by itself; it suggests further investigation.

What does predictive analytics use?

Historical data and models.

What is fairness in claims handling?

Treating all parties reasonably and consistently.

What is the goal of trial preparation?

To organize evidence and witnesses for presentation.

What is a witness statement?

Information provided by someone with knowledge of the loss.

What is the Insurer's mission in claims?

Fair and timely resolution of claims.

What is coverage?

Protection provided under the policy.

What does a plaintiff do?

Brings a lawsuit.

What does the SIU investigate?

Potentially fraudulent claims.

What is a conflict of interest?

A situation that may impair professional judgment.

What is the value of claims data?

Supporting better decisions.

What is accurate documentation?

Complete and factual claim records.

What is damages evaluation?

Determining the value of a loss.

What is negotiation?

The process of reaching an agreement.

What is a defendant?

The person or entity being sued.

What is intentional deception for financial gain called?

Insurance fraud.

What should ethical decisions be based on?

Facts, law, policy, and ethics.

What is benchmarking?

Comparing performance to established standards.

Why collaborate with other departments?

To improve claim outcomes and business decisions.

What is active listening?

Carefully hearing and understanding information being provided.

What is claim closure?

Final resolution and closing of a claim file.

What is discovery designed to obtain?

Information and evidence.

What is objective fraud investigation?

Investigating based on facts and evidence.

What should accompany data analysis?

Professional judgment.

What is trust built on?

Ethical and professional conduct.

What is claim performance measured with?

Metrics and KPIs.

What is a recorded statement?

A documented account of information provided during an interview.

What is legal responsibility called?

Liability.

What is the purpose of settlement authority?

To approve payment within authorized limits.

What is the purpose of a fraud investigation?

To determine the legitimacy of a claim.

What is collaboration between claims and data experts intended to achieve?

Better decision-making.

What is bad faith?

Unreasonable claims-handling conduct.

What is a claim trend?

A recurring pattern observed across claims.

What is a thorough investigation important for?

Coverage, liability, and damages decisions.

What is litigation?

Resolving disputes through the court system.

What is fairness during negotiation?

Seeking a reasonable resolution based on facts.

What is a suspicious billing pattern an example of?

A fraud indicator.

What does predictive analytics estimate?

Future outcomes.

What is reasonable claim handling?

Acting fairly, honestly, and promptly.

What is one measure of claims success?

Cycle time.

What should adjusters avoid during investigations?

Bias and assumptions.

What is the purpose of evaluating liability?

Determining legal responsibility.

What is one purpose of discovery documents?

Obtaining evidence and information.

What is the key element of insurance fraud?

Intentional deception.

What is one major benefit of leveraging claims data?

Identifying trends.

What is professional conduct?

Behavior that reflects ethical standards and responsibilities.

What is the purpose of a claim file?

To document claim handling activity and decisions.

What determines claim value?

Liability, damages, and evidence.

What should a good negotiator rely on?

Facts and preparation.

What may justify an SIU referral?

Multiple fraud indicators.

What is one defense to bad faith?

A bona fide dispute.

What is the purpose of trend analysis?

Identifying recurring patterns over time.

What is complete documentation?

Thorough recording of all relevant claim activity.

What is the ultimate goal of ethical claim handling?

Fair and reasonable claim resolution.