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CCarr
Canada
1200 Posts |
 Posted - 10/02/2002 : 08:22:20
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Fire Scene Investigations - Tips & Techniques
(C) BUILDING & CONTENTS FIRE LOSS CONSIDERATIONS
(1) Structural considerations
After you get past the cause and coverage issues relative to the fire loss you are handling, you then should look at the "big picture" specific to the required repairs of the damaged structure.
In a minor kitchen fire, we are focused on the area of origin or the one room where the fire damage exists, and must consider its betterments, fixtures and components that made it a "kitchen"; with secondary attention to smoke and water damage in other rooms in decreasing severity.
However, in the medium to severe kitchen fire, the fire spread is usually much greater; and before you scope each room you would be wise to first give consideration to the overall structural integrity of the dwelling.
The support members, such as an existing wall construction, floor frame or foundation - not directly in the area of origin - may not have been damaged by fire; however, in order to properly repair the fire damaged area the support components must be structurally adequate to support the eventual retrofit repair and reconstruction of fire damaged areas. In these cases, often, a structural engineer may have to be retained to provide a structural analysis. Too often you will find, due to additions and renovations to an older dwelling over the years, that there has been improper design and construction of some of the structural components, that will compromise the integrity of the structure when the fire damaged components are gutted to make way for the reconstruction of the affected area.
This also may be where you will first encounter "Ordinance or Law" considerations in the policy to be concerned with, as it may relate to the structural characteristics found in the dwelling versus code required elements of the reconstruction phase.
An unaffected structural component that supports the retrofit repair may have been improperly designed and constructed in the past. The structural inadequacy in the design and construction of that support member will affect the retrofit repair. If the claim is in an area governed by a Building Code, you a/o your retained expert must ensure that the ultimate repair that ties into the inadequate portion, complies with the structural adequacy required by code.
If you are working in an area where dwelling construction, renovation or retrofit are governed by a Building Code, it may well be quite similar to this one, that is present in my area; " .... where existing interior walls, ceilings, or floor assemblies are substanially removed in an existing building, and new interior walls, ceilings or floor assemblies are installed within the building; all structural elements shall be constructed in compliance with all the requirements of the complete Building Code ....".
What this means, is that when extensive structural retrofit repair occurs within a building, the retrofit repair must be in compliance with the total Building Code, which includes support for the retrofit repair.
Knowing where to "start and stop" with this concern of providing structural adequacy, can be a dilemma where you encounter haphazardly constructed or renovated older dwellings. The Building Code in my area does not govern the building components and support members that are beyond the area of structural damage; therefore I have parameters established. From a claims cost standpoint, the adverse affect is that often a costly expert (structural engineer) is required to provide expertise in assessing structural integrity, and the code requires me to "make good" inherent deficiencies discovered in the affected area and the "tie in" area. An additional adverse affect is trying to establish this cost consideration of the "make good" factors, if "Ordinance or Law" coverage is not available. The benefit of a clear Building Code is twofold, in a way it sets the direction of your structural scope and defines "how far" your concern for inherent deficiencies must extend.
Another important area of structural concern in a fire loss, is deterioration from the elevated temperatures of a fire in a dwelling. There may well be no physical signs of fire damage to some structural components, but the heat alone can cause significant damage. This area of concern, I have found, is more prevalent in dwellings less than 10 years old. Wood framed components exposed to elevated temperatures from a fire are normally more easily recognized by charring to some degree on the component, but heat damage to steel and concrete are not easily recognized. It is the steel (more and more of it used in new home construction) and the concrete components (foundation and sometimes HCB walls) that a structural engineer is best utilized, to determine the reduction in strength of those components.
Fire generally creates temperatures in excess of 1000 degrees F. Most building materials are not stable at or above this temperature level. Building materials undergo physiochemical changes and transformations in their microstructure, resulting in permanent changes to their structural properties, and hence their stability. The yield strength of structural steel will be reduced to approximately 1/3 its original strength when exposed to temperatures above 1000 degrees F. The structural steel undergoes substanial contraction at these temperatures, which reduces the elasticity and thermal expansion of the material. The elasticity of concrete will also decrease rapidly when exposed to temperatures above 1000 degrees F. Concrete can loose up to 50% of its original compressive strength - and it is the compressive strength of concrete that is the factor in determining its structural integrity - when exposed to the noted temperatures.
We as adjusters are not equipped to determine heat damage to steel and concrete, and the structural engineer is the appropriate expert to evaluate these conditions. This can be a "hard sale" to a carrier at the time, when the examiner or supervisor is not familiar with the affects of heat, and can only "see" these components as "undamaged" and hence not an element of concern. This "hard sale" will likely be encountered when you seek permission to retain a structural engineer, and try to explain that although there is no physical fire damage to the foundation or steel structural components, the heat patterns flowed over certain exposed surfaces of these elements. Prepare yourself for this conversation by noting the composition of the fire's fuel - was there a lot of plastics and other synthetics that have a burn temperature much higher than the "average" at above 1000 degrees F (review the "chemistry of fire" segment for the temperature ratio of plastic over wood combustion). Prepare a sketch or diagram, noting the area of origin, fire spread, thermal heat flow patterns, and the exposed elements intersecting one or more of those conditions. This will show a number of important things to the carrier personnel you are dealing with. First, it clearly indicates you "have a handle" on the loss, then it indicates you "know your stuff", both of these will create credibility and respect in the eyes of the carrier. Then dealing with the actual technical issue and your question and request, you will have presented it with technical competence, and you will find the carrier appreciates your concern and agrees with your recommendation.
I have seen the unfortunate result, when these components were not examined for the affects of heat, either through lack of concern or awareness of the factor; or the declined request for an expert examination. Once the retrofit repair progressed a/o was completed, steel components with no previous apparent deflection, had now visibly deflected and concrete was crumbling.
In summary, look at the "big picture" before you tackle your room to room scope. Determine where heat could have flowed or "pocketed" for a period of time, and what components had exposure during that time. Often, your scope can not be completed until fire affected wall or ceiling coverings are removed to allow a visual examination for any fire damage behind those coverings or inherent deficient construction; or until an assessment is complete for heat affected stress on components.
Recommended reading for this segment is found at www.claimsmag.com
Go to february 2001 - "Expert tips on floor replacement / restoration". This is one of two articles that will be suggested for review on the third surface area other than walls and ceilings. This is a general article, covering many varieties of floor coverings, and the author's (a restoration contractor) viewpoint on the subject. |
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CCarr
Canada
1200 Posts |
Posted - 10/04/2002 : 12:24:01
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Fire Scene Investigations - Tips & Techniques
(C) Building & Contents fire loss considerations
(2) Damaged wall & ceiling systems considerations
Part 1 - Plaster
I am dividing this segment into two sections, the first for plaster surfaces and the second for drywall surfaces; as each is uniquely affected directly and indirectly by fire, heat, and resultant water.
The extreme temperatures generated by a hostile fire inside a dwelling can quickly destroy the integrity of common wall and ceiling systems such as plaster and drywall (a.k.a. gyprock, sheetrock, gypsum board).
There are some easy "tell" signs that the heat has been extreme enough or prolonged for a sufficient length of time, to damage plaster and drywall; even when those items themselves may show no visible signs of damage. They are mostly found at or near ceiling height, due to the nature of the heat rising. These "tells" can include, distortion of plastic items such as a ceiling light fixture, or smoke detector covers. A specific picture of any "tell" is often very helpful in later "selling" your scope of damage.
During a fire, plaster and drywall may be exposed to any combination of damaging conditions as follows; elevated ambient temperatures, intense radiant heat, direct flame, rapid cooling, introduction of moisture, pressurization of the surface from thermal and steam expansion.
Dealing with plaster surfaces affected only by fire, heat or rapid cooling, there is likely delamination of the plaster from the wood lath, if you notice one or more of the following;
(1) large open cracks in the surface
(2) bowing of the ceiling or wall surface
(3) areas where the plaster has fallen and exposed the lath
Unless the above types of damage are very minor in area, replacement of that area and out from it to a clearly undamaged area, is required. Failure to replace this and a sufficient area out from the delamination of the plaster from the wood lath, creates a safety hazard due to the weight of the material and the likelyhood of a delayed failure and possible collapse, at some later time.
In older homes, often the homeowner will want / choose an overlay of drywall, over the cleaned and sealant primed plaster affected area of the wall or ceiling. Correction of the delaminated area, is still a prerequisite, if this route is chosen.
Often times a more serious fire damage issue with plaster are the structural problems of delamination of the finish coats, which can be more difficult to detect. To determine if there has been delamination of the finish coat from the base coats of plaster, tap on the finished surface with your measuring tape or similar solid object.
(a) if a firm or resilient tap is heard, the plaster has likely retained its bond to the base coats
(b) if a hollow or shallow type tap is heard, this likely indicates a bond failure.
Using this method, you can isolate the damaged area and determine your scope of repair. Failure to recognize this type of plaster delamination, scoping only to clean, seal and paint; will likely result in latent failure of the surface, becoming visible in the form of new paint later peeling from the surface. When this type of delamination is found, journeyman "mud - men" have advised that the delaminated finish coat must be removed, then apply a bonding agent and refloat the surface. If the affected or adjoining wall texture or finish does not allow for a seamless tie - in, additional skim a/o texture coats may be required.
Dealing with water damaged plaster, as resultant damage from a fire, steam or very high resulting humidity, can be a difficult aspect of the overall damages.
Plaster is a much more water resistent material than drywall, however when wet, it usually takes 2 to 3 times longer to dry plaster than drywall. This is due to plaster being a heavy, dense material; quite different than drywall. But as well, commercial applications of plaster have fibers added to the wet mix to help hold it together, while it is setting. In older dwellings with original plaster, the fibers used in the wet mix were often horsehair, straw and sometimes asbestos. These fibers absorb water quickly, but release it slowly.
As with any water damage claim, the three basic steps would also apply after a fire, when water has affected the surfaces.
(1) stop the source, and remove standing water
(2) control the interior environment (air movement, humidity, and temperature) to accelerate evaporation
(3) locate and deal with pockets of saturation, as these areas will be slower to dry
Plaster walls or ceilings tend to attract typical pockets of saturation, after sufficient exposure to water. The absorbed water evaporates slowly, especially when finishings such as vinyl wallpaper or enamel paint form a partial or complete vapor barrier over the surface.
If there is extensive areas of plaster in the fire damaged dwelling, and it appears from your observations that a fair amount of water was used by the FD; considerable claims money could be saved by quickly utilizing a commercial vendor to expediate "control of the interior environment".
Extended saturation of plaster may create;
(a) softening of the plaster, creating the possibility of a dangerous, sudden and heavy collapse of a section of surface
(b) the plaster may delaminate from the wood lath, or the wood lath strips may absorb enough water to swell; putting a great stress on the mechanical bond of the plaster to the lath
(c) plaster finish coats may delaminate from the plaster base coats
(d) lime in plaster may reactivate from contact with the moisture and go back into solution; this would cause a calcium carbonate build up on the surface after it evaporated, called "liming".
Set plaster should be hard, solid and rigid. Any flexing or softness, aside from any visible damage; likely means it has been damaged.
Complete R&R of water damaged plaster is usually required, if you notice any of the following;
(a) you can indent the plaster with your thumb, or pushing it with the flat of your hand you detect a "give" to the surface
(b) there is delamination of the plaster from the wood lath (metal lath seldom delaminates), i.e. large open cracks, bowing of the surface area, broken "keys" (that curl of original wet mix that dried between the lath strips - that is where the "mechanical" bond is formed)
I would strongly suggest, where the above conditions are present - and hence require the removal of the plaster - that;
(a) removal of wet plaster is a fair bit cheaper than the same for dry, and it is a lot less messier
(b) but more important, do not get involved (i.e. your estimate, or concurrence with a contractor) with any suggestions to overlay drywall from where the wet plaster was removed. As you can not control when that process may be done, you have no control of whether the drywall would be laid over still wet wood framing on the wall or ceiling; hence creating a trap for the "M" word to enter the scenario, with possible latent affect to the completed R&R process
Repair of the "less" water damaged plaster is more likely the choice, if you notice any of the following;
(a) you feel crackling, flexing, or minor give on the surface; when you press firmly on it with the flat of your hand. This likely indicates the possibility of finish coat delamination
(b) the "tap" technique previously mentioned gives you a hollow or shallow type of tap (on dried plaster); usually indicating a bond failure between the coats
In these cases, after the plaster is thoroughly dried, the usual approach would be to scrape off the delaminated finish coat, apply a bonding agent, refloat the surface, and apply blending skim or texture as required.
When "liming" results from the exposure to water, white or gray small crystals become visible on the plaster surface - after drying is complete. The resultant damage can be readily repaired with a light scraping of the surface, followed by an acid wash surface coat application, touch up as required and paint. Paint will not bond to the plaster surface if liming is not first thoroughly removed. |
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CCarr
Canada
1200 Posts |
Posted - 10/07/2002 : 15:44:48
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Fire Scene Investigations - Tips & Techniques
(C) Building & contents fire loss considerations
(2) Damaged wall and ceiling system considerations
Part 2 - Drywall
Drywall (a.k.a. gyprock, sheetrock, gypsum board) is the most common construction material used for interior walls and ceilings. It comes in many varieties due to the composition of the paper or core being modified to provide designed characteristics such as fire resistence, strength, or moisture resistence.
Whenever drywall is referred to here, it is in context with regular core product, the most commonly used in residential construction. Its common characteristics make it effective in slowing the spread of fire, because drywall is not really dry. Gypsum is a hydrated calcium sulphate mineral, and if you looked at the chemical formula for gypsum you would see it contains a lot of water. Therefore, drywall inhibits or slows the spread of fire because most of the water in its chemical composition must first be driven off by heat as steam, before any combustible materials behind the drywall will get hot enough to ignite.
The following are indications of heat damaged drywall, that are normally not repairable; and require R&R of the affected area.
(a) burnt away paper or burnt seam / joint tape
(b) scorching of the paper surface of the drywall. Scorched paper has little if any strength
(c) Calcination of the drywall. Gypsum, the compound in drywall, is damaged beyond repair by extended exposure to heat above 250 degrees F. Of course, this is over the boiling point of water, and with extended exposure, about 75% of the moisture in gypsum has been driven off as steam. This causes the composition to undergo a chemical change - calcination - converting the gypsum to what is commonly called "plaster of paris".
An adjuster usually can determine if this type of heat damage exists, when it may not be readily visible; by considering the following.
(a) to determine damage to the face paper, scrape away paint or wallpaper with a utility knife, until you reach the actual drywall paper surface. Observe the color of the drywall paper, it should be a light pale grey color. If it is much darker or black, it has been heat scorched, and should be replaced. Take a photo of this specific observation, to "sell" your estimate.
(b) to determine if there is heat damage to the gypsum core, remove a small section (1" - 2" sq) of drywall. Peel off the drywall paper (remember, it should be light pale grey in color) from both sides of your test piece of drywall. Place the gypsum compound in a bowl with a small amount of water and stir it up good. Continue adding a bit of water and stirring until the mixture forms a thick paste. Then wait 20 to 30 minutes. If the gypsum "sets up" like plaster of paris, it has been calcinated; and the affected area should be replaced. If calcination did not occur, the paste will still be wet or dried only to a soft consistency. If the paper is undamaged, this area of drywall can usually be repaired and restored.
The same characteristics that make drywall reasonably fire resistive, make it much less resistent than plaster to water damage. Regular core drywall is a sandwich of gypsum between paper. Both the gypsum and paper are water absorbing materials. As you have likely seen from other types of claims, other than fire, water can wick about 4 feet up drywall from a water line; but also as damaging is that drywall can absorb large amounts of water vapor directly from damp air. Therefore, the after affects of water on fire - steam, condensation, high humidity - will have a damaging affect on drywall in the exposed areas. Further, when drywall reaches a high moisture content, it softens and bends easily and therefore is quite susceptible to the structural stresses occuring during and immediately post fire time.
However, it is easier to extract water from drywall than plaster. For a comparative look, unfinished drywall has 10 times the capacity of unfinished wood, to pass water vapor. That is one major reason why you would observe a competent restoration company utilizing their commercial drying equipment in such a manner as to inject dry air directly into wall cavities, so it can contact the more highly permeable unfinished back of the drywall.
Wetting and drying of drywall does not destroy physically undamaged drywall, as long as the bond of the paper to the gypsum remains intact. Whenever drywall is installed on other than flat surfaces, it must be soaked so it can easily bend to fit curves when installed. There is no glue bonding the sheets of paper to the gypsum slurry, when drywall is manufactured.
An adjuster can usually determine if delamination of the drywall paper has occured. After the wet drywall has dried thoroughly, cut a 1" "X" through the drywall paper, but not into the gypsum material. Pull gently on one of the points where the "X" cut intersected. If the face paper does not pull away easily, and when it does pull away it has gypsum bonded to the paper; it has not been delaminated and can be repaired. If the paper pulls away easily from the gypsum material, the drywall has delaminated, and should be replaced. Again, a good "photo op" to "sell" your estimate.
I am leaving mold out of this discussion. This discussion is within the context of fire related damage. I am not qualified to discuss the affects of mold, nor do I have the required field experience in dealing directly with mold; to be able to bring it into this discussion.
Recommended reading for this segment is found at www.claimsmag.com.
Go to December 2000 - "Residential water losses: Dry it out or throw it out". This article deals almost exclusively with floors, as did the reading from the previous segment. It appears to be a more detailed article than the previous one, and perhaps will give a better understanding and guide to losses on the third major surface of a dwelling - the floor. |
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CCarr
Canada
1200 Posts |
Posted - 10/09/2002 : 12:21:22
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Fire Scene Investigations - Tips & Techniques
(C) Building & contents fire loss considerations
(3) What is "clean", can it be saved?
Considering the dwelling structure, often after a serious fire loss, thought and evaluation must be focused on whether the overall remains can be rebuilt, or whether it is "best" to demolish the structure and totally rebuild.
There is no definitive "point system" or evaluation technique associated with this evaluation. However, I have found that an individual review of the building component systems, and an assessment of their part in the fire damaged status; is often helpful in arriving at a "technical" conclusion to the problem.
Foundation - is it all intact? Has any of it - and if so what portion - been exposed to heat stress?
Below grade excavation - If there is some concern for the foundation, or any considerable portion of it, will replacement require extensive excavation work?
Basement walls - as a distinct building component system, what degree of damage exists? What is the load bearing affect on grade level components?
Floor construction - are the joists and cross bridging intact? Is the subfloor intact, or what defined area needs replacement? Can floor coverings be laid over a repairable subfloor surface, with no further structural regard for the sub structure?
Roof construction - what level of charring is found on the rafters? Is it simply a scrape and seal remediation, or is twinning or some replacement needed? Is the sheathing affected in any way that requires structural repair other than cosmetic cleaning and sealing? Has heat pocketed that could have caused heat stress to asphalt shingles?
Exterior walls - has the framing been exposed to heat and fire? How widespread? Is the exterior sheathing affected? Normally, the exterior finishes (vinyl, aluminum, wood) will be fire a/o heat damaged at fire escape points (such as windows). How far out from these obvious areas does the heat a/o fire damage extend?
Exterior doors & windows - depending on the quality and size of the dwelling, to what extent is this component system affected? Many times this segment will not be a major consideration, but at other times these openings could constitute up to 17% of the exterior area, and their quality and costs usually escalates with their percentage of area.
Interior partitions - segment these by load and nonload bearing areas. What percentage of each requires replacement?
Interior finishes - what is the quality and continuity of the various finishes that require replacement, and how does that relate to the overall interior finishes?
Specialities - list them all, and define their characteristics and individual value. Is there any continuity in the cabinetry in the kitchen, to that of the den, family room, etc. There could be considerable value with built in specialities. As a group, what amount of replacement is required?
Plumbing - how many bathrooms and how many fixtures in each? What is the basic supply service (copper - what size?, or PCV)? To what extent has the fire, heat, or debris damaged the service and fixtures?
HVAC - has the system itself been affected by heat, fire, debris, smoke or water? Duct work for FA systems is cheap, and cheap to install during new home construction. But, quite labor intensive to retrofit during a dwelling repair, if there is widespread damage.
Electrical service - has the service panel been exposed, first was the cover plate off or on? Then, any exposure to heat, fire, smoke, water, or debris? Replacement of the service panel itself and reconnecting the distribution wiring is secondary in cost to damaged wiring in numerous areas throughout the dwelling. I would definitely want an electrical service to be certified or otherwise, after a fire. I have a large concern for heat stressed sheathing on wire and oxidized wiring connections to fixtures and fittings.
These are not all the issues and concerns to evaluate, the specific conditions you face will dictate the extent and scope of this review and evaluation to determine what the "best practice" may be regarding repair or rebuild.
You must be aware at this time whether there is "Ordinance or Law" coverage available. If so, that makes the process a lot easier, unless the carrier wants a specific costing of the claim elements attributed to "O or L".
Further, usually in concert with the carrier, after you have completed the aforementioned evaluation; you must weigh the ALE projected costs. A retrofit repair incorporating the undamaged areas, can at times (if the fire damage is severe or widespread) take as long or longer if things do not go real well; than demolition of the shell and a total rebuild. Sometimes, to go to one extreme, the insured's will move comfortably in with relatives, and the ALE claim is a small portion of its potential. Other times, likely the other extreme, you are forced with putting the insured's up in several hotel type rooms; with all meals and services at additional cost.
I see the HO3 deals with "same site" and LKQ, under Loss Settlement as; ".... the RC of that part of the building damaged for like construction and use on the same premises ....". Invariably, an insured faced with a major retrofit repair or total replacement, will come up with some "visions" of changes they have always wanted to make. Often there is little or no significant dollar affect to the total project, and these things can be incorporated with little time expended by you or the time of construction - so as to have none or minimal affect on the overall claim. At other times, you will have to spell out clearly what "same site" and LKQ mean to the project; and the insured can make their own deals or arrangements later with their chosen contractor.
To "clean" is often a misused term relative to restoration following a fire claim; where heat, smoke, soot, and water are present. The combination of these elements and compounds often bring into use the following "words".
Pathogen - "disease causing", airborne pathogens can cause us to get sick; whether its walking down the street or the post fire environment of a dwelling.
Microorganisms - "invisible living things", that require nutrients to live; some are safe and some can be fatal.
Antimicrobial - a substance, mechanism, or condition that inhibits the growth or existence of an organism. Usually a general term to describe various compounds often found in consumer products, that have the ability to limit, control or stop the growth of microorganisms.
Disinfect - A misused, overrated term in the restoration industry. Its intent is to destroy 99% of microorganisms. Disinfectants can only be applied to hard surfaces, and are of no use on textiles.
Sanitize - "to reduce the number of bacterial contaminants to safe levels"; simply just making the area hygenic for human use. Textiles can be sanitized.
Disinfect and sanitize - a misused term, no one common commercial compound can do both. A carpet can be sanitized, but disinfectant is only applicable to hard surfaces.
"....CIDE" - "to kill", a fungicide is meant to kill fungi, as a different "cide" such as bactericide is meant to kill bacteria.
Biocidal compounds - used commonly by the cleaning and restoration industry. They contain alcohol, chlorine bleach (sodium hypochlorite), hydrogen peroxide, iodine, or synthesized phenolic compounds.
All of these chemicals and compounds are used with varying success by restoration people to remove and eradicate the affects of smoke and water, or that elusive "M" word.
With contents, from clothes to textiles furniture; it is best to remove the items from the affected premises for cleaning and storage until the dwelling has been totally repaired.
There is a night and day difference between the results of a good drycleaner, specializing in smoke and water damage cleaning than one that is not very experienced at this process. Rely on your carrier for their PV's in this field. They have gone through the agony of unsatisfied customers and have likely found good and effective PV's in this field.
The success of this cleaning is also often rooted in the physical characteristics of your insured's and the degree of care taken to rehab the fire damaged dwelling.
First regarding the insured's, the concept is similar to how the same perfume will react on different people. A person's body temperature and the environment in which they wear their clothes and theur activity, will determine if any very minor amounts of lingering organic compounds that are responsible for the odor of smoke - do in fact reappear. The drycleaner, you, and the insured, may each "sniff" a garment after cleaning and be pleased that you do not detect the odor of smoke; only to get a call several weeks later from an insured complaining of smoke odor in their clothes.
Each fire has a different make up or smoke signature - no different from cigarettes to cigars to pipe smoke - due to the different quanties of wood, rubber, plastic, colth, vinyl, etc, that was burnt.
The same applies to furniture. Seldom is it the "phantom foot" syndrome of the amputee manifesting itself in a lingering memory of the fire. In fact, unfortunately it is likely an inadequate cleaning process or the too often reused cleaning solvents, that are too laden with smoke compounds. It can also be the hypersensitive sinuses of the insured's.
If heat, smoke, soot, and water have heavily penetrated clothes closets; often it is best to test clean 10 or 15 items and let the insured wear them to see the results, before mass cleaning of affected clothing. Often this test will also disclose if in fact the stains from heat, smoke, soot, and water are removable; let alone the odor of smoke.
With more and more synthetic fabrics being used in clothing and furniture, it is getting harder to clean these items and remove odor; resulting in required replacement.
However, perfectly cleaned and restored clothing and furniture can later be brought back into a dwelling that did not have all smoke, soot or char properly removed and sealed. Come a damp day, the dwelling and its contents will absorb lingering smoke odors; and you will be confronted with an unhappy insured. |
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CCarr
Canada
1200 Posts |
Posted - 10/10/2002 : 22:18:40
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Fire Scene Investigations - Tips & Techniques
(C) Building & contents fire loss considerations
(4) Damage to textiles and fine art
This segment is intended to increase your awareness of the "make up" of textiles, and the affect fire can have on them; more than specifically what to do with fire exposed textiles. Hopefully, it will allow you to discuss these affects professionally with an insured and a commercial restoration company; and avoid the "whitewash" that may be presented to you as "solutions".
Fibers are the essence of clothing, upholstery, curtains, and carpets. Fibers come in two basic categories - natural and synthetic.
Common plant based natural fibers are cotton and linen, while animal based natural fibers are wool and silk. Common synthetic fibers in textiles are polyester, acrylic, nylon and acetate.
Without a product label to read, it is easy to determine whether a fabric is natural or synthetic. If the product is fire damaged, you will observe that natural fibers burn and produce ash; whereas synthetic material melts and produces a hard "bead".
As I have noted in other segments, natural and synthetic materials react differently when exposed to fire; and they are dealt with differently after a fire.
Natural fibers - cotton, linen, wool, silk; are generally affected by fire and resultant damage from fire as follows.
Water damage - may cause shrinkage and deterioration over time
Soot and smoke damage - absorbed easily, but also released fairly easily
Smoke odor - absorbed easily, but also released fairly easily
Acidic damage - not as vunerable as synthetics
Heat damage - considerably less sensitive to low heat levels than synthetics. Cotton and linen are more susceptible to low heat exposure than wool and silk
Biological damage - highly susceptible to organic growth
Synthetic fibers - polyester, acrylic, nylon and acetate; are generally affected by fire and resultant fire damage as follows.
Water damage - generally unaffected
Soot and smoke damage - very sensitive, discoloration is very common, damage amplifies until appropriate cleaning is completed
Smoke odor - often odors can be difficult or impossible to remove, due to chemical bonding of smoke hydrocarbons to the synthetic fiber hydrocarbons
Acidic damage - very sensitive due to chemical reactions
Heat damage - synthetic fibers are types of thermoplastics, which usually melt at 400 degrees F, but they will soften and distort at temperatures starting at 200 degrees F. Common damage is loss of strength, without apparent physical damage - you will be able to easily pull the garment to shreds
Biological damage - generally do not support organic growth. If you walked into a clothes closet about 48 hours after the clothing has exposure to some heat, smoke, and lots of water; the natural fabrics will be very visibly growing mold, while the synthetics will not
So, as you can see, synthetics are much more vunerable to the affects of fire, heat and smoke; than natural fabrics.
Complicating this further, are the blended fabrics (composition of natural and synthetics), often found in upholstery and curtains. Often when you look at some of the product labels, you will note a composition of up to eight different types of fibers used.
Different fibers, whether natural or synthetic, react differently to smoke exposure, acidic residue, heat and any cleaning process. Therefore, these "blends" are often more difficult to restore than a single fiber item.
Fabric material products are more often rendered a total loss due to their decorative purpose, than their utilitarian function. A wooden piece of furniture may be economically stripped and refinished and serve its purpose again; while fabrics are chosen for their appearance. Minor degrading of appearance, regardless of cleanliness, will often result in unacceptability by the insured.
Shrinkage and loss of shape, will often be caused by water exposure or cleaning. Natural fibers such as cotton, silk, wool, rayon, and jute; are particularly vunerable to shrinkage and loss of shape.
If a fabric is backcoated with latex or other similar material, such as would be used on carpets, curtains, or upholstery; often limits the cleaning success.
Colors, patterns and dyes found in fabric material also are adversely affected by fire and resultant damage; and their success at restoration is limited.
Don't let a restoration contractor load up their truck with all the contents and a promise to "fix and clean" everything, later to tell you we tried our best as you are handed a large bill for attempted restoration of a significant inventory you now have to consider as a total loss. You are the adjuster, take charge of the loss. Review and agree with the contractor what may have a good chance of restoration; and armed with the common affects noted above - discard the rest after an inventory has been prepared sufficient to allow you to consider proper evaluation and LKQ.
Fine art, however is an area where successful restoration is often more likely achievable. But, it is paramount that a specialized vendor be utilized. Be sure you know who your carrier has established a successful relationship with regarding art restoration. Damaged "art" is often a very sensitive issue to the insured, more so than a lot of their other contents; due to the often significant sentimental value placed on the item. More expensive "fine art" is normally insured with a rider or endorsement on a "valued" basis. Therefore, with those pieces, you know the parameters and limitations of your restoration "dollars".
Again, from an adjuster's viewpoint of "art", the key is to know what vendor in your area specializes in art restoration or conservation.
This is not the work for a "normal contents restoration" company. Fine art restoration requires comprehensive knowledge of artistic techniques used over the ages. Improper techniques, although the piece is visibly "restored" to your eye or mine, could well significantly reduce the value of the piece. Proper restoration is achievable on art ranging from low value to high, including photographs, multi litho copy prints, limited litho prints, all types of paper, and original paints of all types. You will find that art restorers are not quick to accept a piece to restore, until they have examined it and determined if in fact they feel they will be successful. Their reputation is in restoration, not the attempt of it. This is a healthy attitude, not common with most general contents restoration vendors.
I have found the work of art conservators to be quite economical, normally based on labor and material costs, and not a percentage of the items value. But, in that context, you must be comfortable with the value of the item pre-fire; so you can conclude whether it is economical to proceed with estimated restoration costs.
Recommended reading is found at www.claimsmag.com
Go to December 1999 - "Reality estimating in the property insurance industry". Although off topic to this chapter, it is an interesting article to study. It talks of the general downfalls of estimating software, and discusses the fundamental argument of unit cost pricing versus the time and material method. The author concludes that there must be better methodology to organize an adjuster's scope, so there can be a better "meeting of the minds" between adjusters and contractors. Finally he suggests, adjusters should have more basic construction industry experience, to bring reality into the usage of the numerous estimating software programs.
This concludes this chapter. In this chapter I hoped to give some guidelines to consider following a fire loss. It is suggested that the total structure has to be reviewed and considered beyond that of visible fire damage, and due consideration given to applicable building codes as to how they may affect the retrofit repairs. Plaster and drywall ceiling and wall surfaces were discussed, and the contrasts in their susceptibility to fire and resultant damage. We suggested that the individual building component systems should be considered and assessed as a method of evaluating the technical aspects of whether you might be faced with a total loss, and that other claim elements should also be weighed to then make a "best practices" decision on how the claim should be resolved. Finally, some restoration issues affecting common contents were discussed, contrasting the fire affects of the two basic types of fibers.
Next chapter, we will deal with the "sleuth" aspect of claims.
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CCarr
Canada
1200 Posts |
Posted - 10/13/2002 : 22:02:15
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Fire Scene Investigations - Tips & Techniques
(D) Forensic primer
(1) "Red Flags"
Part 1 - an overview
A "red flag" in the context of fire investigations is a sign, an indication, a warning, a clue; that something is "not right", that something or things about the claim cause you to start to form opinions that require specific investigation to determine if an illegal act or act that would void or exclude coverage has been committed by the insured or at the direction of the insured.
Up and down the long ladder of "red flags", at varying stages of the claim we will encounter terms that are applicable in our dealings with this chapter.
The following terms should be reviewed and added to your "tool box", so when encountered you will understand the context in which they are used.
Evidence - oral testimony, documents, or physical articles that are properly submitted to a court or judical body of fact
Demonstrative evidence - in a legal proceeding, physical evidence - a gas can, a contract, photographs; evidence other than tesimony
Documentary evidence - evidence in written form, i.e. a report; that is allowed to be presented
Prima facie evidence - evidence that by itself establishes the claim of a party, or the defense of a party; if it is not rebutted or contradicted
Discovery - the gathering of evidence before a trial begins by a party to the action. Each party to the action has a right to question or depose the other, submit written interrogatories, review evidentiary documents in the other party's possession, and inspect property owned by the other party (i.e your claim file) when relevant to the case
Deceit - an action or communication intentionally based on falsehood or the withholding of material facts, that induces another to part with a legal right
Fraud - any act or omission with a view to illegally obtaining an insurance benefit. This definition encompasses the full range of fraudulent acts - from completely fabricated claims, to the inflating or padding of legitimate claims, to false statements on insurance applications
Misrepresentation - a false oral or written statement made with the intent to deceive
Material misrepresentation - the intentional concealment, distortion or fabrication of a material fact
Expert witness - a witness whose testimony is based on specialized knowledge. The witness's expertise must be pertinent to the facts at issue, and the witness must possess sufficient education, training or experience, to be accepted as an expert
Forensic expert - an expert who assists the courts in applying specialized knowledge to legal principals and the facts of the case. Forensic means - pertaining to arguments or legal proceedings
Bad faith - in general, dishonesty, unfair dealings or deceit
bona fide - an act done without deceit, fraud, dishonesty or pretense; a sincere effort made with earnest intent. Latin for "good faith"
Burden of proof - the term often means the standard of proof, or the quantity of evidence required to win a case. In criminal law, the prosecution must prove each element of the crime "beyond a reasonable doubt" to establish guilt. In civil law, the standard of proof is less, a party must demonstrate its claim by a "perponderance" of evidence, meaning that the offered proof must have more credibility or weight or be more likely than the other party's
Proof of Loss - a document that provides a sworn statement by an insured to an insurer. The form includes the date and description of the claim, and the amount and details of the loss claimed
Fraud is one of the most difficult illegal acts, relative to an insurance claim, to have proven; in order to avoid paying indemnity. This burden of proof is most difficult to establish in a criminal proceeding, where it must be established "beyond a reasonable doubt"; whereas in a civil case (the insured suing the insurer for the denied claim) the burden is reduced to a "balance of probabilities".
At the judical level, not all "misstatements" or "inaccuracies" advanced by an insured constitute a fraud. Because of the way the courts tend to favor the "lowly insured", we must distinguish between the "overly enthusiastic" insured and the dishonest one. Exaggeration of a claim is not conclusive of fraud, because value is often a matter of opinion. But, exaggeration would be proof of fraud, if it is made in a dishonest manner, or if it is so excessive that it could not have been made in good faith.
The burden of proving fraud, lies with the party who alleges the fraud. Suspicion of fraud, no matter how serious, is insufficient. There must be convincing and compelling evidence.
Fraud negates an insured's claim, if an insured knowingly makes a fraudulent statement or misrepresentation that relates to a material aspect of a claim, and causes prejudice to the insurer.
Some courts have held in civil cases, that once fraud is established, no matter how slight the amount, the entire claim within the Proof of Loss fails. Other civil cases have established that false statements in a Proof of Loss regarding the contents portion of the claim, resulted in a dismissal of the claim for both building and contents. A false statement made in an application for homeowners insurance may have the same result, if found to be material to the claim at hand. However, throughout all this, courts will allow the insured what seems like wide ranging latitude to "explain away" the alleged fraud.
There are four basic "places in time" where an adjuster must look for and recognize "red flags".
(A) Pre-loss "paper" - the insurance policy, the application, and subsequent underwriting communication both from the insured to the agent, and the agent to the underwriter.
(B) The loss - the insured, statements, scene of the loss.
(C) Post-loss "paper" - documents, receipts, any "paper" produced by the insured, or developed by your actions with others; that are relevant to the loss or pre-loss circumstances.
(D) The Proof of Loss - the properly completed legal document.
In part 2 of this segment, I will get into the "red flags" that could be found and recognized in the first two "places in time" areas.
Recommended reading is found at www.claimsmag.com
Go to March 2002 - "Are we steamed up about fraud? Or is it just hot air?". This is an interesting article, starting with the author's views of how fraud started to escalate in insurance claims. He goes on to characterize and explain the two types of insurance fraud that are commonly called "hard" or "soft" fraud. To me, the most pointed argument he makes is in relating the increase of $82M in fraud bureau budgets to that alternatively being spent to hire 1,640 new "field adjusters" to adjust claims "the old fashioned way", which he explains in a way that I find nostalgic.
In my opinion, insurers are taking the "investigation" out of adjusting, with the creation of and growing industry segment of SIU's. To me, this is the wrong approach, and it is starting to surface as such with some carriers, as they witness the lack of cooperation and festering animosity between claims and SIU units; a situation that in some cases is worse than the age old general dislike between claims and underwriting departments.
It is wrong to take the "investigation" out of the hands of the adjuster, because it breaks the continuity of the "adjustment" process, when you limit or exclude an adjuster from exploring all the dusty trails he/she may recognize as needing explanation each logical step of the way. Further, newer adjusters coming into the industry, will never be allowed to "investigate" and hence will unknowingly join the new army of claim processors; thus missing the opportunity to learn and get exposed to one of the most interesting and rewarding aspects of a claim adjustment - the investigation. |
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CCarr
Canada
1200 Posts |
Posted - 10/14/2002 : 21:40:21
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Fire Scene Investigations - Tips & Techniques
(D) Forensic primer
(1) Red flags
Part 2 - Pre-loss paper & the loss
In this segment we will explore "red flags". Again, it is important to recognize that all a "red flag" is meant to be is - a sign, an indication, a warning, a clue; that something is not right. They each are just another stone that needs to be overturned and explored. Do not stereotype an insured based on recognized "red flags". These clues must be studied to determine their validity or circumstance relative to the claim. It would not be uncommon to recognize two or five "red flags" that the limits of your investigation could not substaniate. Success lies in the ability to do what is required to recognize the "red flags", then carry or direct the investigation to reach a proper conclusion with each clue.
(A) Pre-loss paper - the insurance policy, application and subsequent underwriting processes.
Perhaps staff field adjusters are better able to be proactive in this section, due to the logistics. However, any conscientious claims manager, on assigning a serious or questionable loss to an I/A, will first examine for themselves the policy, application, and all communication between the underwriter and the agent. If that occurs, regardless of who is assigned to the claim, the claims manager will provide copies of relevant policy papers to the handling staff or I/A adjuster. If you don't get this data, ask for it, and explain why you need it.
It is critical that the underwriting data be reviewed, often it provides the first "red flag" clues; or at least will confirm the basic use and occupancy of the structure, from which the underwriter accepted the risk and set the rate.
It has been well established in past court cases, that the insured has a duty to provide the insurer with complete, truthful and accurate information when applying for the insuranve coverage; and when the coverage is in place to disclose any material changes in the risk associated with the property.
Watch for signs, indications or clues of these "red flags" -
(1) in the application, false or misleading information that was provided, relative to your observations
(2) failure to report any previous insurance claims, that may be disclosed to you
(3) failure to advise of previous insurers cancelling any policies, that may be disclosed to you
(4) the insurance was placed "just before" the loss, usually within a week
(5) within the week prior to the loss, the insured contacted the agent to confirm coverage and its extent
(6) prior to a loss, the coverage is increased either by an amount or scope of coverage
(7) failure to advise that the property is or has become vacant
(8) failure to advise a change of use for the property
(9) failure to advise the property is deteriorating
(10) failure to advise any changes in title for the property, or lien / mortgages on the property
Knowing how the "declaration page" of the policy is printed, the contents of the application, and any relevant underwriting communication concerning the policy; will allow you to watch for and recognize the above "red flags" as you look and listen to the insured and facts you discover at the loss site.
(B) The loss - the insured, statements, scene of the loss.
The basics of any fire investigation within the goal of determining cause, is an indepth discussion / interview / statement taking process from the insured; and a thorough physical examination of the scene of the loss. This must be done on your terms and planned in advance. You will develop your own style, but remember how I said I liked to "work into" the process by first (after the hellos) walking around the outside perimeter of the structure, and do a lot of looking and listening and not much talking. This often allows me to make early decisions on "best practices" on how to next proceed with the goals I have established.
When it is time to have an indepth discussion with the insured, many "red flags" can surface at that time, watch for -
(1) the insured can not be contacted directly, or a third party family member (but not an insured by definition) often tries to deflect you away from the insured
(2) the insured refuses to discuss the specifics of the loss
(3) the insured refuses to provide a statement
(4) the insured seems overly familiar with claims procedures and terminology
(5) the insured frequently threatens to retain a lawyer, but does not follow through, when asked to confirm who it is
(6) the insured frequently throughout any discussions says he has consulted a lawyer, but will not provide the name
(7) the insured speaks of his awareness of the system because of the other claims he has had over the years that he tells you of
(8) the insured is overly eager for a quick settlement, having a clear figure in his mind at your first meeting; that is often an amount which your early observations would conclude to be considerably less than its value
(9) the insured's eagerness to quickly resolve the claim is rooted in his comments about his current financial, marital, employment, gambling, abuse, business, or medical problems
(10) the structure where the loss occured had less of a pre-loss value than the land on which it sits
(11) the insured, regardless of your style and method of questioning, will only come out with consistently vague and useless information
(12) the insured is overly calm about the loss, may even act pleased or relieved to a certain extent about the loss
(13) the insured changed their pattern / routine prior to or at the time of loss
(14) the insured family members a/o pets were absent prior to the time of loss
(15) the insured was not on the premises at the time of loss
It would not be uncommon even in an accidental fire, to recognize and have surface at least five of these "red flags"; while discussing the loss with the insured. Each, depending on the specifics of your claim, must be explored to determine their validity and importance to your file. You may be encountering a "dazed" insured, or one that smells the opportunity for greed following the accidental loss.
When specifically conducting your thorough physical examination of the scene of the loss, watch for signs of these "red flags" -
(16) again, stressing the importance of my "walkaround", both of the exterior perimeter and the room by room complete interior; based on the relative size of the structure, how does the amount of or lack of debris relate to the structure and the loss?
(17) are any, or many, contents out of context with their usual location; i.e. the remains of a plastic gas can or other flammable liquid container in the kitchen or other "not likely" spot?
(18) at any accessible door or window, are there any signs of forced entry?
(19) prior to you arriving on site, is the insured now telling you at the scene, that he has already discarded property that would form part of his claim?
(20) is there a lack of physical debris in the area of origin?
(21) do you recognize a large spread of fire, relative to the reported cause?
(22) do you recognize more than one fire area of origin?
(23) do you recognize that a very hot intense fire burned in the area of origin, that may not be consistent with the claimed cause, or contents usual to that area?
(24) the fire occured early in the morning or late at night, a time of day when a fire is more likely to go undetected for a longer period of time
(25) the insured was the last seen and provable person to be at the scene, prior to discovery of the fire
(26) there is an installed fire alarm system with central station monitoring, that was not operative at the time of fire
(27) there are installed smoke detectors, that were found to be removed or their power source removed
(28) public authorities from their preliminary work, state the cause of the fire as "undetermined".
(29) the property is listed for sale, and likely has been for sale for more than 30 days, without any significant interest shown by potential buyers
(30) coverage provided in the policy, far exceeds your early estimation of value
(31) the insured automobiles were not parked in their usual place, i.e. garage, or close to the dwelling
(32) your interior "walkaround" causes you to believe that usual contents are absent or have been removed prior to the loss
(33) your "walkarounds" cause you to believe that the structure has not been maintained, or that it has been "unoccupied" prior to the loss
Again, it would not be uncommon to recognize and have surface at least five of these "red flags" while you are examining the scene. To get to the root of these types of "red flags" you often have to ask direct questions to the insured a/o liaise with public authorities that attended, or dependant on the "flag" retain an outside expert. You can not shy away from directly confronting the "clues" you have encountered. You must explore them to see where they take you with your investigation.
In part 3 of this segment, we will conclude looking at "red flags" that could be found and recognized in the last two "places in time" areas; post-loss paper and the Proof of Loss.
Recommended reading for this segment is at www.claimsmag.com
Go to September 1998 - "Fire Investigations: Site evidence leaves few easy answers". This is an interesting article by an author who is a fire investigator, with a police and claims background. The theme of the article is not to look at a loss site with "blinkers on" or with tunnel vision. You must have an open mind, and not subscribe to stereotypical theory. He defines a successful conclusion to an investigation as, ".... finding the true cause of the fire using all the evidence available ....". |
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CCarr
Canada
1200 Posts |
Posted - 10/15/2002 : 23:05:22
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Fire Scene Investigations - Tips & Techniques
(D) Forensic primer
(1) "Red flags"
Part 3 - Post-loss paper and the Proof of Loss
(C) Post-loss "paper" - documents, receipts, any "paper" produced by the insured, or developed by your actions with others; that is relevant to the loss or pre-loss circumstances.
At this stage of the claim and ongoing investigation, you have to carefully review any "supporting paper" the insured provides; and often you must find other relevant and helpful documents. Depending on the specific issues related to your claim, the basic premise is that the insured must prove the extent of their claim; notwithstanding the "estimate" you may ultimately produce. This basic premise is founded in the policy, in the Conditions - "Your Duties After Loss" - (e) "prepare an inventory of damaged personal property showing the quantity, description, actual cash value and amount of loss. Attach all bills, receipts and related documents that justify the figures in the inventory". (f2) "provide us with records and documents we request and permit us to make copies ....".
Now, as you know, 6 or 7 out of 10 "normal" residential fires, you will not need to invoke these Conditions "to the letter". However, when you do, when "red flags" have surfaced by this time in your investigation, these Conditions are the root of your authority to seek such "paper". If you are starting a "paper trail" for a certain element or segment of the claim, you are looking for receipts or invoices that will substantiate or otherwise, the claimed items of the insured.
During this process watch for these "red flags" -
(1) the insured claims all receipts and invoices were lost in the fire. Where were they, what room, what drawer? Paid by credit, check, debit, or cash?
(2) the insured claims all purchases were in cash. Banking records will reveal cash flow patterns.
(3) the insured does not remember where all or most claimed items were purchased
(4) the insured does not remember when all or most claimed items were purchased
(5) the receipts that you are provided with are all photocopies
(6) the receipts that you are provided with are all consecutively numbered
(7) the receipts that you are provided with are from a generic receipt book, not retailer specific printing / stationary
(8) the photocopied receipts that are provided appear to be altered
(9) the dates on invoices / receipts do not match financial records that are reviewed
(10) "rounded / even dollar" amounts are consistently used on the receipts that are provided to you
(11) appropriate taxes for the point of purchase are not added, or if so are incorrect
(12) you are unable to track the supplied receipts to any financial records
(13) the receipts that are provided to you all carry the same type font or handwriting
(14) actual invoices are provided to you only for low value items, and no substantiation is offered for higher value items
(15) you can not verify the invoices provided to you with the retailers noted on the invoices
One of the most interesting claims I did, that illustrates the value of exploring these "red flags", was back in the late 70's. As a claims supervisor then, I was surprised one morning when a $800.00 theft claim was assigned to me by the CM. It was a homeowners claim that I recognized the name of the insured to be someone working within the insurance industry. Still, I took it to my CM and asked if I got it by mistake, and he said no and told me to hit the road and keep him informed.
Well, it was a claim that then and today, would normally be a 7 minute telephone adjust. But, in my initial conversation with the insured, "red flags" #2,3,4 went up; and as I explored under those stones "flags" #5,7,8 surfaced. After #4 and before #5, I sent the insured the "required letter" providing him with a blank Proof of Loss, noting the requirement for its proper and statutory completion. That resulted in receiving a phone call, and the inured jabbing at me why I was being so "technical" and that my boss would hear about it. So, I received #5, and then noticed #7,8. I went to the retailer and convinced them to search their records, resulting in a form of #15 and confirmation of #8.
Trying to condense the facts for you, this led me to the local police detachment, where I explained what I had. With something to work with they verified the information and took control of the "evidence" (something that would not happen today - we'll get to that when we deal with Public Authorities), arranged an appointment with the crown attorney, who advised when the Proof of Loss came in; if it was proper, charges would be laid. This all happened in the midst of the insured trying to bully his $800.00 claim through, and after rejecting the first Proof of Loss received, finally got a proper one; and the person was visited by the police and charged with attempted fraud. A real theft that had occured of about $400.00, that was fraudulently misrepresented as an $800.00 claim; cost this person his career and no end of anguish to him and his family. It is terrible when "one of our own" abuses the "cookie jar".
Aside from using this example to illustrate the benefit of finding, recognizing and exploring "red flags"; it is an unforunate example of the high claims costs associated with this type of claims investigation. My time as an adjuster was far disproportionate to the value of the claim just with the investigation aspect; let alone the time incurred to attend each segment of the ensuing trial which resulted in a finding of guilt.
(D) The Proof of Loss - the properly completed legal document
This is an essential document if you have "red flags" that have been explored and led to a fair but unfavorable position for the insured.
If the document is properly completed, the insured is swearing to the truth of the information in the Proof of Loss, regarding the loss claimed. Fraud or attempt there at, on the part of the insured through false or misleading statements in the Proof of Loss; is convincing and compelling evidence sufficient to void the claim.
The adjuster must never prepare the Proof of Loss for the insured to sign, nor assist in any way in its completion. I have seen more than once, where an insured has pleaded reliance on the adjuster and "confusion" in the communication from the adjuster regarding the Proof of Loss completion.
Again, the policy sets out in its Conditions, the insured's requirements, if you request a Proof of Loss be completed. Any "assistance" you offer should be limited to referring to those Conditions and advising the insured to read them and seek their own help to comply with them.
So, now during the course of your investigation to date, you have reviewed and considered (A) pre-loss paper, (B) the loss, (C) post-loss paper; you may or may not have recognized any "red flags" to this point, or if you did they may have been all satisfactorily resolved. Now, with the fully and properly completed Proof of Loss at hand, this is your last opportunity to ensure that the claim is valid.
With the Proof of Loss, watch for these "red flags" -
(1) the amount of contents claimed could not have been contained in the area where stated
(2) certain claim elements are exaggerated
(3) the insured is claiming for property he did not own
(4) the insured is claiming for items that did not exist
(5) the insured is claiming for items that were not damaged
(6) claimed items are identified that were not purchased where or when claimed
(7) the insured is claiming replacement value for items that are repairable
(8) the Proof of Loss claim is for replacement of items, when only ACV coverage is applicable
(9) the insured fails to disclose, or incorrectly discloses, who else has an interest in the property (i.e. mortgages or liens).
Another interesting claim I was involved in first about two years ago as part of the original site investigation team, illustrates the value of exploring all "red flags". It was a major fire loss in a high value home. Through the various stages of the investigation relative to this "red flag" recognition exercise, the following signs, indications, warnings, clues arose.
(A8&10) - the insured was not living at the property (actually living about 1000 miles away) and had rented it to a cousin, and two additional mortgages had been placed on the property since the policy was issued, and had not been disclosed to the underwriters.
(B1,2,3,5,6,11,12,14,15) - odd, when your home burns down and you don't make the time to "get things going" with the adjuster. When the insured finally (several weeks later) takes some time, he is too busy to discuss the loss, and has no time to provide a statement. Pushed for his cooperation, he "throws lawyer" around in the conversation. Through all this, even with his $600K house in ruins, it doesn't seem to bother him and he only offers vague answers to any questions. No one was on the premises at the time the loss was discovered.
(B18,21,24,25,28) - observations and discussions with Public Authorities (FD) reveal that all doors were locked and they had to force their entry to the interior to suppress the fire, and that the fire was well spread upon their first arrival, at 1.30AM after receiving a call from a neighbour at 1.25AM. The tenant cousin was seen by the neighbour leaving the premises about 12.30AM, as the neighbour was turning off his lights to go to bed. The next day the FD must class the fire as undetermined, because they can not establish another acceptable and provable cause at that time.
The insured made his claim via a Proof of Loss with an attached 86 page Schedule of Loss addendum to the Proof of Loss, some 11 months later. Therefore, (D) revealed the following (C).
(C1,3,4,12) - a $1M contents claim, with no receipts - none? Less than 20% of the claimed items in the Schedule of Loss had any reference (other than "unknown") as to where or when purchased. Refer later to (C12) - a rock worth turning.
(D1,2) - these "flags", as well as (C12), proved to be the downfall of the insured.
Perhaps with this example I should have limited the discussion to (C12, D1,2), however, it at least illustrates that not all "red flags" can be resolved, and even due to specifics, some unresolved "red flags" do not become conclusive evidence to support fraud. It can be a frustrating exercise.
However, (C12) was a long but worthwhile trail to explore. Although there was no receipts, I gathered from the Schedule of Loss the items claimed as purchased at about 10 high end retailers and hit the road. Cooperation was mixed, but when provided, a search of computerized client profiles and purchases; revealed no such client a/o purchases.
(D1,2) - the contents of a wine cellar were claimed at 842 bottles of expensive and detailed vintages. The day after the loss (with the site having been secured by authorities overnight) one of my chores was to inventory the wine cellar; so with portable lighting and lots of photos, 100% of the inventory amounted to 210 bottles in a lovely custom made wine cellar that had a capacity of only 400 bottles. You do not know at the time what value those dark and dirty hours invested will bring in the future. The Schedule of Loss claimed those individual bottles with an accumulated value over $50K. So now, 11 months after I did the inventory in the wine cellar, I was now verifying the cost of claimed inventory and establishing the cost of the inventory I took. The actual price of claimed inventory was about $22K, and the actual price of the inventory I took was about $8K.
This "grunt work" on (C12, D1,2) is actually one of my favorite elements of investigation. It leaves me with a solid feeling, either the claim is valid or it is not. It is the results of exploring these "red flags" that provided convincing and compelling evidence that fraud was being attempted by the insured.
Carriers will remember the value added benefit you brought to an investigation, when you diligently explore all "red flags" you recognize.
In closing on "red flags", those listed are by no means an exacting or total list. The emergence of "red flags" is unique to each specific claim, and your methods to recognize them.
Recommended reading is at www.claimsmag.com
Go to September 2001 - "The evolution of insurance fraud detection - lessons learned from other industries". This article will give you an insight on how other industries combat fraud, and how some of those methods are being implemented by insurers both on the front lines and behind the scenes. |
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CCarr
Canada
1200 Posts |
Posted - 10/17/2002 : 00:23:02
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Fire Scene Investigations - Tips & Techniques
(D) Forensic primer
(2) Suspiciousness and the ability not to stereotype
In part of this segment, I want to review and summarize the two basic words in the title - suspicion and stereotype.
Your success as a good investigator, brings into play two essential skills - the technical skills, which I hope this series has provided you with some additional foundation for; and for want of a better term - "professional attitude", which I tried to provide some positive things to think about way back in the first chapter.
A couple of times now in various segments I've said, "I cann't overstate the importance of this ....", or repeated myself in a segment trying to say the same thing in a different way to make a strong point. This next portion is one of those. You can have all the technical skills, policy knowledge, degrees or accreditations, that will make you a machine to do a claim - and you do need a good measure of those tangible items; however adjusters must have a clear mindset each and every time they touch a file.
An adjuster must always fight against drawing conclusions from suspicion. To "suspect", is to think or feel that something is likely or possible. Your decisions in claims must always be rooted in facts. If you think or feel someone has done something that would void or exclude the claim, or if you think or feel there is no coverage for a certain loss; you must be able to prove those thoughts - or coverage or indemnity will ultimately go with the insured. Many times during the years you put in investigating claims, you will "think or feel" very strongly that the claim shouldn't be paid; because of "red flags" you recognized, then explored but could not conclusively resolve. The carrier examiner or management, may in your eyes, give your thoughts little regard; and direct the claim to be settled. This is not because they do not care, or that they do not share your "thoughts and feelings". It is because they have learned the hard way, that to deny a claim that lacks convincing and compelling evidence, is fruitless and counter productive.
Stereotyping is a common fault of our society as a whole. We all could count off several varieties of stereotyping we see or hear each day.
It is a condition that also generally prevails through claims. An insured makes certain comments and he is perceived as greedy, or worse. We encounter a dwelling or premises, different in so many ways from our own, and the owner is perceived from a perfectionist to a slob. I have found this has been a more difficult problem to address with telephone adjusters, than it is with adjusters who work in the field. Likely because of the general difference in years of experience, but also attributed to all the information coming to telephone adjusters through one sensory focus - what they hear on the phone. Whereas, field adjusters get several sensory views, being both what they see and hear.
A successful adjuster, will always approach each new claim with an open mind, with a goal to achieving each of the "3Cs"; which will ultimately lead to a payment of the loss. You must shed yourself of the bad experience that may have been your last call, and start fresh with each individual you encounter. Let your investigation and adjustment of the loss speak for itself and the final resolution of the claim; not your perception of the person you are dealing with.
In the first segment on "red flags", the recommended reading article I mentioned brought forward the concept of "hard" and "soft" fraud. It is the soft type of fraud that normally leads to the greatest frustration of having sufficient convincing and compelling evidence to successfully prove your "thoughts and feelings". An excellent article that expounds far better than I could on soft fraud is found at www.claimsmag.com. Go to - September 2000, "A lie by any other name .... Hard truths about 'soft' fraud". The author, a defense lawyer, details many of his exploits and observations faced with these claims.
Another article I reviewed reminded me of a possible solution to consider, when you have convincing evidence; that may not be viewed as sufficiently compelling.
Once I recognized the strategy, but not by the name given, I do recall only about five times where I was involved in the process in about a 20 year period; and three of those times it worked but with a different technique.
The article at www.claimsmag.com, July 1999, "Letting them walk, claims withdrawals save time, litigation costs"; is worthy of review.
This, and what I will relate, should only be attempted by the carrier claims management. You may suggest it, if they don't, or ultimately aid in the preparation for it with the carrier.
I have no experience with or knowledge of a "Claims Withdrawal form". However, when all aspects of an investigation are complete and your review with the carrier concludes that yes you do have a quantity of convincing evidence, but the concensus is that perhaps (whether gun shy or prudent) that evidence is not compelling enough; perhaps it is time for "showdown" with the insured.
The concept is simple, the carrier calls the insured to their offices to discuss the claim; there is no mention at the time of setting the appointment of the word "settlement". The insured to this point has dealt with you - that "big, bad, mean I/A; and the invite by the carrier claims management will normally be viewed optomistically by the insured.
You (the handling adjuster) and the carrier supervisor or manager, will lay out all your convincing evidence on the table in a meeting room. When the insured arrives, the carrier management takes charge of the meeting and summarizes what information and facts have been provided to him; with his best "poker face". The conclusion is noted that the claim appears to fall outside the scope of one that should be paid. However, in the interests of all concerned to avoid litigation, perhaps a settlement can be achieved.
In my opinion, this is fair ball. It is not a bad faith ovation to the insured. Other carriers given the "paper" of the investigation, would not hesitate with the information at hand to deny and defend. Perhaps even the involved carrier on another day - past or future - would deny and defend.
The 3 of the 5 claims I was involved with this and it worked, were a fire, burglary and a bodily injury. The two where it didn't work, were also within those types.
The fire and bodily injury claims, were soft fraud, with exaggerated claims. The fire had many aspects of the contents claim way out on the big side of inflated; while the bodily injury to the arm of an airline pilot which he claimed kept him from flying for a national airline, was fluff - clearly illustrated in some great video we had of him helping to construct an addition to the church he belonged to. The burglary was a fabricated claim on a lot of scheduled jewellery that our PI had bought back a few pieces in a rather innovative "sting".
The object, after the carrier carefully lays out how they see the claim and the clearly presented convincing evidence - is to see who will blink first. The insured may "huff and puff", but you have to read the real reaction. If there is a Mr and Mrs Insured, they both should attend. This may be the first time the Mrs is made aware of "what's the holdup on payment" is about. I have seen a Mrs go into a rage right at that meeting - but it is directed at Mr; a good "tell" for your side.
The carrier in this approach is looking to achieve a settlement, of what they believe the true actual value of the claim is, or when it is believed to be a fabricated claim some measure of payment to release them from the claim.
The fire claim - which was inflated - was settled for about its real value; clearly discounting the total inflated portion.
The burglary claim - which was fabricated (and claimed as per schedule values at $60K) - was settled for $1K and a lawyer prepared release executed.
The bodily injury claim - a minor injury that the pilot was taking advantage of to get the summer off, with the help of his doctor providing supporting reports - was settled for $2K plus special damages and a proper release.
The message is that this technique saved a bundle of claims dollars that were not due to the people, and saved a bigger bundle in potential litigation defense costs. Another equally important message is that "revenge" or extracting your "pound of flesh" is a bad rut to get into. Everyone in the claims process of adjustment should be looking for the "best" way to resolve the claim.
The other two attempts at this technique, just resulted in the insureds walking out and prolonged the stalemate; to be settled later without litigation on a compromise basis - or as they say today a "win-win solution" for all parties involved.
We must all realize that there is more than one way to battle "improper" claim demands. But, you have to know what battles to pick and when to pick them. |
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CCarr
Canada
1200 Posts |
Posted - 10/23/2002 : 23:45:52
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Fire Scene Investigations - Tips & Techniques
(D) Forensic primer
(3) The statutory authority of the Fire Marshal
First, I apologize for being tardy, I both got behind in my preparation and had some current claims work to attend to.
This will be a difficult segment to address everyone, due to the wide geography of the reading audience; probably 99% of which is American.
In my small part of the continent, Ontario, the Office of the Fire Marshal (OFM) is part of the Public Safety Division, of the Ontario Ministry of Public Safety and Security. However, that link to a provincial government, or State, is not the same in each jurisdiction.
The same is found in my reasearch of this office in the USA. In Texas, for example, the SFMO comes under the authority of the TDI. For those working in the Lone Star State, the SFMO produces a worthy periodical called, "Fire Lines", that would keep an adjuster that is working fire claims in Texas abreast of developments within the SFMO. Those in Texas should review, www.fire.marshal@tdi.state.tx.us" target="_blank">www.fire.marshal@tdi.state.tx.us and those in other states, interested in fire claims, should do a similar web search.
In the State of New York, this body is referred to as the Office of Fire Prevention and Control (OFPC), under the authority of the NYS Department of State.
However, my review of numerous jurisdictions, allows me to reasonably conclude, that there is a continuity of purpose to the Fire Marshal in each area. The OFM or SFMO (et al) have sweeping powers of investigation once a fire has occured. They have the authority to enter and seal off land and premises without a warrant, or to remove, examine and retain any article or material; and to take samples and photographs.
Some municipalities have trained fire investigators either employed in their fire service or police departments. However, the "Office of the Fire Marshal", is from where that investigators authority is generally ceded. If a municipality does not have trained fire investigators, they could under certain scene circumstances, and are mandated by other scene circumstances, to ask for an investigation by the "Fire Marshal".
You will encounter these people at a fire site, either from the outside of a secured area, or on site if there is no longer a need for the scene to be secured. My experience has been that they are seasoned and veteran cause and origin people, but working for a public authority as a public servant.
It will serve you well, to get to know these people who do this work in your region. In my area, these people are known to attend as public speakers a few times a year at insurance industry functions, or at the regional adjusters associations you may belong to.
They will serve as the investigative link between a municipal fire service and the police service, to determine cause and origin of a fire. However, if evidence of incendiarism is discovered during a Fire Marshal's examination, the examination must stop. The fire scene then becomes a crime scene. That means, that the authority the Fire Marshal used to enter the scene, and the authority the Fire Marshal exercised to find evidence of incendiarism, no longer exists. From then on, authority and evidentiary rules are guided by the applicable Criminal Code.
When the scene is still a "fire scene", there is much you can learn from a Fire Marshal, and discuss with them. This improves with time, with your increasing rendeavous with them at fire scenes, or a friendly hello and chat at their next public service function. These people have explained more to me about fire patterns than I'll ever get out of a book, and seemed glad to do so at the end of a day at a fire scene; during a 15 minute wrap up discussion.
There is often a "give and take" with a Fire Marshal, during a fire scene investigation. You want to know who assigned him and why and what he saw and can tell you. The Fire Marshal wants to know what you have developed, the essence of your investigation with the insured or other sources, and of course the "insurance history" - "Part A" of any "red flag" developments.
However, once the fire scene turns to a crime scene, you must not allow any "give or take" to happen with a Fire Marshal or any other public investigative body.
The reasons for this apparent contradiction, is found in the body of the next segment of this series.
Recommended reading is at www.claimsmag.com.
Go to September 2002 - "Documenting the interview". This is an excellent article to consider and review relative to investigative interviews and statement taking. |
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CCarr
Canada
1200 Posts |
Posted - 10/24/2002 : 22:33:24
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Fire Scene Investigations - Tips & Techniques
(D) Forensic primer
(4) Co-operating with Public Authorities
An insured has had a fire occur at their residence, the fire service has responded to suppress the fire. The fire service due to whatever they saw, feel obliged or mandated to call in the Fire Marshal to confirm origin and cause. In the meantime, the insured promptly reported the fire loss to his agent, who in turn promptly reported the claim to the insurer - and an adjuster was assigned.
Within a short period of time, quite a collection of interested parties are involved in the investigation of this fire. These parties could include, the fire service, the Fire Marshal, the police service, the agent, the carrier, the mortgagee or loss payees - each operating under different legal authorities and with different interests or agendas.
Primary to the interests of all parties are;
(1) protection of the fire scene
(2) identification, collection, handling, examination and retention of any evidence
(3) the gathering and collection of information of investigative value, to confirm or eliminate how and why the fire started, and who may have caused it
(4) damage assessment and valuation
It is at this point that you - the adjuster - must be aware of the pitfalls of sharing information with the different interests involved.
All of the interested parties have one common goal in their efforts - that no one benefits from a deliberate or criminal act. However, all parties must recognize and understand the competing interests of the criminal justice system and that of the civil justice system.
The goal of the criminal justice system is punitive action and behaviour modification. The goal of the civil justice system is compensation for wronged parties. Therefore, the sharing of investigative information by the adjuster, with parties outside the insurance contract can be counter productive to each parties interests.
Some of the most common counter productive results of an adjuster sharing investigative information with Public Authorities are;
(1) the exclusion of evidence
(2) civil actions for breach of contract
(3) bad faith
(4) conspiracy allegations
(5) malicious prosecution charges
(6) libel or slander accusations
(7) invasion of privacy charges
Having responded to the fire, the fire service and the Fire Marshal must comply with their statutory duties imposed by the legislation that is effective in their region. The Fire Marshal investigator will assist the fire service in determining cause and origin of the fire. The respective municipal and State "Freedom of Information" type legislation and "Privacy Acts", will govern the release of information gathered by the fire service and the Fire Marshal.
As stated in the previous segment, once incendiarism is discovered by the fire service or the Fire Marshal during their investigation at the fire scene, that investigation must stop; and the fire scene now becomes a crime scene.
The crime scene investigation now has different legislative authorities governing its conduct, and the evidentiary rules are now guided by the applicable Criminal Code.
It is now up to the appropriate police service to advance the investigation and attempt to develop sufficient evidence to charge someone under the Criminal Code for the wrongful act.
Law enforcement agencies will only lay charges based on evidence. Normally, their evidence is reviewed and analyzed by a crown attorney, to determine the likelihood of securing a conviction.
The sharing of investigative information by the carrier - via the adjuster - for the crown attorney benefit, could seriously damage the position of the carrier; both for any proper resolution of the claim but also any civil action that may arise from the fire.
A carrier sharing investigative information with parties outside the insurance contract, exposes the carrier to potential financial risks as follows;
(1) waiver of any legal privileges the carrier may want to rely upon in defence of the claim
(2) the carrier defence lawyers loss of strategic advantage in the discovery / deposition process, due to the premature disclosure of your investigative file to the plaintiff; during the criminal disclosure process
(3) the greater risk of the handling adjuster being personally sued, causing the defence to have to engage in defending every investigative and administrative step performed on the file
When the handling adjuster - whether I/A or staff - is personally sued, defence lawyers are very concerned about the overall outcome of the case for the following reasons;
(1) does the handling adjuster have the requisite experience to testify under oath in court?
(2) is the handling adjuster "mentally" prepared to testify?
(3) can the handling adjuster effectively articulate under oath, their personal recollection of what they did, why they did it, and when?
(4) can the handling adjuster articulate effectively and legally support, why they shared investigative information with parties outside the insurance contract?
(5) can the handling adjuster understand, and effectively articulate, the issues surrounding the doctrine of "utmost good faith", privity of contract, and the provisions of any applicable freedom of information and privacy acts?
(6) will the handling adjuster's claim investigation, notes and file materials pass the scrutiny of the civil justice system?
I have witnessed this review and process, and can tell you clearly, that it can make children out of adults.
The role of the adjuster in this fire scenario is to determine the "3C's" - or otherwise stated to investigate, evaluate, negotiate and settle the insurance claim; in concert with any direction from the carrier.
Nothing can be negotiated or settled until the adjuster's investigation is completed. Informed decisions respecting coverage must be based on facts - evidence.
The applicable Insurance Act, the insurance policy, and the doctrine of privacy; are the fundamental authorities governing the investigative conduct of the adjuster. The adjuster's obligation in the conduct of their investigation is to those three authorities - not the law enforcement investigation.
Take a step back, I'll again remind you that at least 6 or 7 of every 10 fire claims you handle - they will not require the involvement of other agencies except the suppression of the fire itself.
However, the adjuster must always remember, while conducting a loss investigation that;
(1) the adjuster is not the "insurance police"
(2) the adjuster does not conduct criminal investigations
(3) the adjuster does not put people in jail
(4) the adjuster's duty is to the contractual relationship with the insured
Adjuster's "acted" much differently 15 or 20 years ago. Part of a successful adjuster's critical network - to get and expediate investigative information - were their contacts with all levels of Public Authorities; and in turn share their investigative information with Public Authorities. This exchange of investigative information, undoubtedly, still goes on to some extent today. However, the consequences of it being uncovered are now quite serious.
Again, the adjuster and the insured are obligated under "utmost good faith" to act with the highest standards of honesty towards each other. The doctrine of privity clearly identifies the rights of those who are a party to an insurance contract. Any breach of the contract, or any party who jeopardizes the rights of another under the contract; exposes the offender to claims for breach of contract and a claim for damages.
Therefore, the adjuster must conduct a separate, independent, objective investigation of a fire loss.
The fire service, Fire Marshal, police service, do not have privity of contract. When an adjuster shares investigative claims information with Public Authorities, the adjuster faces the risk of a bad faith claim.
Now, in the adjuster's investigation, they would not be doing a complete job, if they did not communicate with Public Authorities to determine or confirm if the fire service, Fire Marshal, or police service; did possess any information about a wrongful or deliberate act. If they confirm they did not, that exercise is complete; and you move your investigation along.
If they do confirm that they do possess information about a wrongful or deliberate act, one of the critical points you want to determine is when they changed the fire scene to a crime scene. The rest of the exercise becomes a paper chase. Use the law to your advantage. You can lawfully obtain, in most circumstances, detailed, quality, Public Authority investigative information.
Your search for Public Authority information is now centered at the applicable Court House or County Registry office, and to a lesser extent any "access to information" laws that may be applicable in your area. The procedures will vary by jurisdiction and regionally within that jurisdiction. The Clerk of the Court, or County Registry Clerks, like any other person, will vary in their recognition of your right to the information you are pursuing. However, whatever diligence is required along with a professional approach; will bring about the results you require.
With the adjuster distancing themselves from any accusation of being a "person in authority", or of sharing investigative information with Public Authorities; is one of the reasons why often times a retained outside C&O expert is utilized by a carrier to conduct a parallel C&O investigation to that being conducted by the Public Authorities. As well, this "line drawn in the sand" through judicial developments over the years; was one of the causes for the development and growth of SIU departments within a carrier. This will be explored in the concluding segment of this chapter.
Recommended reading is at www.claimsmag.com
Go to March 2001 - "Getting the most from outside investigators". This is an excellent article as a primer in best utilization of an outside expert.
Also, go to June 2002 - "What, exactly, is an engineer?". This is a good article to review concerning forensic outside experts, specifically engineers. |
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CCarr
Canada
1200 Posts |
Posted - 10/25/2002 : 21:51:34
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Fire Scene Investigations - Tips & Techniques
(D) Forensic primer
(5) Specific recommended reading
In this final segment of this chapter, I also want to discuss SIU departments.
First, I considered the forensic engineer and the bigger scope of outside experts. However, reviewing the two articles offered in the last segment; I have nothing constructive to add of value beyond what is in those articles.
SIU departments became popular with carriers in the early 90's. Their initial purpose was to become the fraud fighting performance tool of a carrier in relation to fraudulent claims being presented. I have heard carrier management characterize an SIU the same as existing subrogation units, the purpose being to allow the "foot soldier" adjuster to adjust 90% of the claims volume that was valid; and turn over the other 10% to the SIU. The comparison being that subrogation untis handled the specific and time consuming task of getting money back, hence allowing the "foot soldier" to work on more claims; and hence the SIU would rid the adjuster of the time consuming claims that were thick with unresolved "red flags".
That concept eroded by the late 90's, when like any other department at an insurer, it had to justify its economic existence. Much debate occured, which you can read in the recommended articles; on how an SIU could or could not justify their costs.
However, it was within that exercise that the "power struggle" emerged, and the SIU role evolved.
Much like a fire investigator working a fire scene that develops evidence of incendiarism that forces them to stop, and the scene and the authority for it changes to that of a crime scene; the original context of the SIU was that they did not get a file until the adjuster identified a probable wrongful or deliberate act.
This process of the adjuster / SIU "hand off" has evolved, to in some cases, the adjuster being required to supply the SIU with all identified "red flags"; and their resolution will be determined by the SIU.
Therefore, like any other inter-department co-existence on issues, turf wars have resulted. Adjusters and their claim managers want to adjust claims, while SIU's constantly refer to their investigative expertise. This is further complicated when an SIU is not under the direct control of the claim manager, at the office where both are located.
Currently, there seems to be a concensus that the role of the SIU is in "flux"; while upper management tries to address and solve the communication problems that have resulted from these "barriers" to co-existence.
Another of the referenced articles explains and discusses the communication breakdowns, and the need to redefine what a referral to an SIU is.
During this period of "flux", some carriers are having their SIU's focus (or in some cases refocus) on the "big crime" picture - rings perpetrating organized fruad, theft and staged accidents; where their joint efforts with the (here) Insurance Crime Prevention Bureau (ICPB) and in the USA the National Insurance Crime Bureau (NICB) could help to develop trends, profiles and benchmarks for some of these rings that annually create millions in claims each year.
The final recommended article touches on the next cycle for SIU's, and; ".... the importance of having adjusters out on the street ....".
I am not, and have not been a supporter of an SIU; beyond their co-ordinated work with national crime bureaus to attempt to circumvent organized insurance crime. As I have stated before, I believe it takes away from the continuity of an adjuster's attempt to adjust a claim; if the adjuster at some defining moment of the investigation has to turn the file over to an SIU, perhaps later to get it back to negotiate and conclude settlement.
For those that argue that the adjuster lacks training in proper investigation techniques, the answer is simple; provide the proper and adequate training after you hire the right type of individual.
Recommended reading for this segment is at www.claimsmag.com. All of the articles are SIU related, and over their 29 month span, you will see the evolution and changing attitude.
Go to April 1999 - "An inexact science: benchmarking success in the SIU".
Go to September 1999 - "Bridging the gap - improving communications between SIU's and claims".
Go to September 2001 - "SIU's: the times, they are a-changing".
This concludes this chapter.
In summary, this chapter was intended to clearly lay out what a "red flag" was, and what you must do with them. It laid out the four basic "places in time" where an adjuster must look for and recognize "red flags", and discussed each of those "places in time". In a rather repetititive way, I tried to contrast "suspicion" from fact; and caution you on avoiding the pitfall of stereotyping insureds. I touched on the authority of the "Fire Marshal", and I again suggest that you become aware of this authority specific to your region of work. In dealing with Public Authorities, I wanted to make it clear, the pitfalls you could encounter by not distinguishing your investigation as your own, and how that relates to the criminal justice system and that of the civil justice system.
Finally, I have posted a note in the Bulletin section of CADO - "Fire thread forum, need your opinion". If you haven't seen it please have a look, and please consider providing your opinion.
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Fire Scene Investigations ~ Tips & Techniques
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