ethical claims management

© 2021 Genex Services, LLC1

Ethical Claims ManagementPRESENTED BY

John J. Tambascia, EsquirePillinger, Miller, TaralloPMTLawFirm.com

March 25, 2021


Over 20 years of experience handling all aspects of complex civil and malpractice litigation. Areas of practice include professional malpractice, products liability, construction, premises, motor vehicle, and cargo litigation. Trial attorney in the state and federal courts of New York, New Jersey, and Pennsylvania. Pioneered the use of scale models to evaluate complex cases. The multiple perspectives of scale models allow him to definitively establish how an event happened.

John J. Tambascia, Esq.

555 Taxter Road, 5th FloorElmsford, NY 10523

p: (914) 703-6300 ext. 1260f: (914) 703-6688 e: [email protected]

mailto:[email protected]


Led Zeppelin lasted for 12 Years, The Beatles Lasted For Ten.

When performing live, Led Zeppelin’s shows were longer. The Beatles usually just stood still and packed it in after an hour.

Led Zeppelin is never recalled for bad songs, but The Beatles are constantly insulted about songs like Revolution 9 and Obla-Di-Obla-Da.

Led Zeppelin did not do singles. Only whole albums.

If you wanted to see the bad you had to go to the concert. No TV.

1.2 Million people applied for 16,000 tickets in 2007!

Led Zeppelin v. The Beatles - Be Zeppelin


I Have No Bias on This Issue.


Allegedly Paul McCartney stated that the concert was too long. However, he was also reported to be smoking and not lucid.

Last Note on Zeppelin


Perception Kills

https://ncadvertiser.com/25841/brazen-act-latest-on-smash-and-grab-robbery-investigation/


Claimants make huge mistakes!


Claimants Are Forgetful


The Reality

Who caused this? You’re both getting tickets!


This is a tough business, and you are not alone.


California

Florida

Texas

Pennsylvania

Alabama

Mississippi

Louisiana

The Special States


What did we sign?

Contracts Are Never That Clear

https://www.thelienzone.com/hold-harmless-indemnification-and-duty-to-defend-there-is-a-difference/

https://www.slideserve.com/lotte/dem


Some things can never be explained


The Insured.

The Company and Investors.

The Claimant.

The Court.

Counsel (Plaintiff & Defense)

Innocent Parties

To Whom is Your Duty Owed?

You are not an attorney.

You have been reminded Ad nauseam that you are not an attorney.

You are not an expert.

You may or may not have a degree in Engineering


You are a fiduciary.

You are a licensed professional.

You process claims.

You verify an insurance policy exists for the insured person and/or property.

You evaluate risk(s) of loss(es), or damages to property, culminating in the loss of property and or bodily injury.

You Are Better Than Those Things


After completing the above investigations, evaluate the covered injuries and/or damages that have been determined according to the coverage grants

Negotiate a settlement per law / coverages / following best insurance practices.

You are a fiduciary.

Adjuster Continued

Ensure resources are not wasted.

Protect the insured.

Prevent overreach of counsel (Plaintiff & Defense)

Investigate liability

Communicating with policy holders (who do to talk to not want you)

Defend against Fraud (SIU LAWS)


Adjuster

A fiduciary is a person who holds a legal or ethical relationship of trust with one or more other parties (person or group of persons). Typically, a fiduciary prudently takes care of money or other assets for another person. You write the checks.

Attorney / Expert

No Authority other than what is delegated.

They cannot write settlement checks.

He is a Porter!

Things You Can Do They Can’t

https://en.wikipedia.org/wiki/Law

https://en.wikipedia.org/wiki/Trust_(social_sciences)

https://en.wikipedia.org/wiki/Party_(law)

https://en.wikipedia.org/wiki/Asset


Adjuster – Analyzes and acts

This is the difference

Attorney – Moves information


This is the first line of defense and attack.

You control the tempo.

You control the engagement.

You place all parties and insured on notice.

You act with speed. Florida Administrative code Section 4(4)f), which states: "An adjuster, upon undertaking the handling of a claim, shall act with dispatch and due diligence in achieving a proper disposition thereof.

The EUO


If at any point in my questioning you wish to stop, we will then agree to continue within a reasonable time to finish taking your statement.

Your carrier wishes to make a completely informed decision concerning your claim. Other than the questions I asked, documents we reviewed, is there any additional information/witnesses you believe should be interviewed, before the carrier makes a final decision on your claim?

As a person making this claim, are you satisfied you were provided every opportunity to share all the information / documentation you believe should be considered before making a final decision on the claim?

Critical Notice 1 - 3


An affirmative answer to these questions by the insured is perhaps the most effective “tool” you may later have to present to a court in support of a motion for partial summary judgment on a bad faith claim and dispel any argument the claim was not investigated thoroughly or the insured was not afforded every opportunity to present relevant evidence concerning the claim.

Why?


Perception:

Sometimes giving someone a second chance is like giving them an extra bullet for their gun because they miss you the first time.

Reality:

Reasonable justification

Why Second Chances?


The standard in deciding whether a claim should be accepted or denied is when all the evidence is considered does it leave you any reasonable alternative other than to deny the claim.

This standard per the guidelines set forth by courts that all matters of coverage should be resolved in favor of the insured where there is any reasonable doubt.

The standard is still reasonable justification. The test should be whether when the evidence is considered in its totality the insurance company has a reasonable basis for the denial. If the evidence, when considered in the light most favorable to the claimant, still leads you to the conclusion a denial is proper, then you have reached an appropriate decision.

The Standard


Misrepresent coverage

Fail to attempt a prompt, fair, equitable settlement

Fail to settle one claim to influence settlement of another claim

Fail to provide reasonable explanation of claim denial

Improper use of the Fair Credit Reporting Act – User of adverse credit information must provide: •written notice of adverse action •name, address and phone of agency furnishing report • information to obtain free report

Unfair Claim Settlement PracticesA laundry list of things a company may not do when settling claims


Any agent who sells or services P & C insurance outside residence state must be licensed in other state(s) before company can legally pay commission

Each state has different laws, procedures, licenses, restrictions, continuing education requirements, etc.

Generally requires a letter of good standing from “home” state

BE AFRAID, BE VERY AFRAID

Non-Resident Licenses


Decide if the problem has legal or ethical considerations• Is it only legal or ethical or does it have both components?• Is the decision necessary?

Gather all pertinent information•How did the problem occur?•Who has “rights” in this situation that should be protected?•Who has obligations in the situation?

Ethical Decision Making


“Establishes minimum standards of expected behavior for those to whom the code applies.”

Insurance industry organizations each have own

Some codes are principles only with no penalties for non-adherence

Other codes hold members accountable and may expel or sanction those who do not meet standards

Code of Ethics


Root is Greek “proper modes of conduct” in a culture.

Current meaning - “conforming to accepted professional standards of conduct”

Not a response to legal restrictions or threat of punishment

An internal, personal decision implying freedom & authority to make individual judgements

Often defined in relation to what is unethical - no concrete answers

Defining Ethical Behavior


Illegal to share commission with ANY unlicensed person - including payment of “bonuses”, “finders fees”, “referral fees” or “incentives” (any valuable consideration)

Solicitor may not “broker” business to or accept commission from any LRA except the appointing agent

False Advertising - printed or published literature intended for public distribution which is untruthful in fact or implication. (Print or visual ads and billboards/sales and form letters/prepared sales presentations/materials included with policy when delivered)

Commission Sharing / False Advertising


Redlining - refusing to write insurance based on location

Unfair Discrimination - refusing to write insurance based on other than underwriting decision

Rebating - providing ANY valuable consideration outside the insurance contract as an inducement to purchase

Unfair Practices Cont’d.


Tie-in sales - making availability of one policy conditional on purchase of another

Sliding - adding coverages to policy without insured’s approval

Twisting- replacing insured’s policy with yours when not in his/her best interest

Churning - replacing current policy with another in the same company when not in insured’s best interest

Unfair Practices Cont’d.


The Elephants in the Room!


The Lions in the Room

Public Adjuster

A representative of the policyholder who advises, manages, and submits a claim on their behalf

They charge Fees

They are averse to the company and insured

Pro Se

They do no know the law.

They may have conflicts.

They tend to be suspect.

They may lie.

They may think you are lying.

They may think everyone is lying.

They may think they think.


Don’t lie you were thinking it.

Pro Se Cont’d

https://en.wikipedia.org/wiki/File:Fluoxetine_20mg_with_Packet.jpg


Do not back down in the face of a disrespectful attorney.

Hold your ground & Demand respect.

You are not an attorney. Use it to your advantage.

Remember the “Safe Harbor”

The Nasty Attorney


Nasty Attorney Cont’d

The Rules of Professional Conduct

They are actual law.

Attorneys are bound by them.

They may work in concert with the court rules.

They enhance laws on discrimination.

Your rights

Right to be treated fairly.

To obtain accurate and fair answers.

Obtain accurate information.

Not to be threatened.


Manager to the Yardbirds and Led Zeppelin.

Had a hands-on approach.

Protecting his band and their finances.

Identified bootleggers or unauthorized photographers

Peter Grant Was Intimidating


Was the shrewdest and most ruthless manager in history.

Improved the conditions for musicians in dealing with promoters.

Furthered financial and artistic control

Be Peter Grant

Understand that you too are a consumer, a member of the public and a professional.

You can cut checks, you can make decisions, you can report fraud.

Peter Grant Cont’d


Most will goad you.

Most will push.

Most will send rude letters.

All will push the bounds of good taste.

They will accuse you of bad faith.

The Nasty Attorney (Again)


You are not doing these things; however, a Plaintiff’s attorney will pounce on every opportunity and door you leave open.

An insurer may be acting in bad faith if the insurer delays, discounts or denies payment without a reasonable basis for its delay, discounting or denial.

Failure of insurer to acknowledge and reply promptly upon notification of a covered claim.

Failure of Insurer to pay a covered claim as a result of failing to do a proper, prompt and thorough investigation as to reasonable liability and damages based upon all available information.

Failure of insurer to affirm or deny coverage of claims within a reasonable time upon receipt of claim and/or proofs of loss.

Insurer attempts to settle a claim for less than the amount to which a reasonable person would have believed was entitled or attempts to substantially diminish a claim requiring an insured to initiate litigation.

Attempting to settle claims on the basis of an application and/or policy which were altered without notice, knowledge or consent of the Insured

Identifying Ethical Dilemmas and the Peter Grant Counter


Remember there is some showmanship to the entire process.

Be polite.

Be direct.

Focus your request.

Remind others of the number of times you requested information.

Get them to acknowledge that they have not given you everything you need.

Advise of SOL’s .

Second chances are to protect you, the company, the insured & third parties.

The Grant Counter


You are not an attorney.

You represent many interest and the truth.

You want information to process a claim.

You are the gatekeeper.

The Attorney’s Legal Malpractice

The other guy is an attorney.

He represents a client.

He needs to give you information to process a claim.

He is a porter.


Some Comic Relief


Improper Questioning

Isn't it true you burned down the house?

You know this fire is an arson, don't you?

Who but you would have wanted the house to burn?

Ask the Right Questions

Proper Questioning

Did you in any respect play any role, directly or through anyone else, in causing this home to be burned?

Based upon the investigation by the local fire department and independent origin and cause investigator, they have concluded this fire is an arson. Do you believe in any respect these conclusions are incorrect? Is there any information you wish to provide to your insurance carrier for it to consider other than this fire appears to be an act of arson?

Based upon the investigation it appears you may have had the means, motive and opportunity to have been involved in this fire. Is there any other evidence you believe should be considered, or any other persons you believe may have reason to have been involved in this loss?


Although the purpose of this letter is to advise you your claim is being denied for all purposes, if you feel our company has failed to consider any relevant evidence or documentation concerning your claim, we will grant you a period of an additional fourteen (14) days from the date of this letter to submit any additional evidence or documentation you wish for us to consider. If we do not receive any additional information from you, then we will assume we have considered all the evidence and documentation you feel is relevant to the proper investigation of your claim.

Denials


No down-side risk. Give the insured every opportunity to explain why the decision to deny the claim is not correct.

If the policy contains a statute of limitations either cite the policy language stating the limitation period or, at a minimum, insert a sentence into the denial letter advising the insured to carefully review the terms and conditions of the policy as it may set time limitations and deadlines for filing of litigation.

Denials Cont’d

Denials of claims - always in writing.

Relevant portions of the policy should be quoted directly in the denial letter, so the insured knows specifically under what provisions of the policy the claim denial is based.

Denials should set forth unequivocally the claim is being denied for all purposes so the insured cannot in any way claim they did not understand a denial was occurring or the reasons for the denial.


The denial letter can be one of the best exhibits in favor of the insurance company in a bad faith trial.

The denial letter will chronicle the extensive investigation undertaken by the insurance carrier, summarize the relevant evidence either presented by the claimant or secured by the carrier during the investigation, give the reader (including jurors) an understanding of the extent of the investigation conducted and cite the specific provisions under the policy supporting the decision to deny the claim.

Denials Cont’d


This is About You

No, not you! The attorney at the other end of

the phone (see below)

Who me?


Per our conversation of the 25th “You” will provide X to me in 15 days.

Per our conversation of the 25th “You” agreed to provide X to me in 15 days.

“You” failed to provide X to me in 15 days as agreed to during our conversation of the 25th.

Simple Tips


Present this – Classic Peter Grant.

Presentation is 90% of the law


Allen Klein and George Harrison in 1970

The man who broke up the Beatles

Paul McCartney sued his bandmates in large part to rid himself of their hated business manager

Do NOT present this


This is about CRCC Sections

L: Resolving Ethical Issues

L.1. Knowledge of Ethical Standards and the Law

L.2. Addressing Suspected Violations

L.3. Conduct in Addressing Ethical Issues

Code of Professional Ethics for Rehabilitation Counselors (CRCC)


Autonomy - right to self-rule Beneficence - do good to others Non-maleficence - do no harm Fidelity - be faithful Justice - be fair Veracity - be honestYou are the Gatekeeper

This is not Psychotherapy, it is about


Addressing Unethical Behavior (CRCC Code of Professional Ethics for Rehabilitation Counselors - Section L2b)

i. Rehabilitation counselors expect colleagues to adhere to the Code. When rehabilitation counselors possess knowledge that raises doubt as to whether another rehabilitation counselor is acting in an ethical manner, they take appropriate action. Conflict Between Ethics and Laws (CRCC Code of Professional Ethics for Rehabilitation Counselors – Section L2c)Rehabilitation counselors obey the laws and statutes of the legal jurisdiction in which they practice unless there is a conflict with the Code.

i. If ethical responsibilities conflict with laws, regulations, or other governing legal authorities, rehabilitation counselors make known their commitment to the Code and take steps to resolve conflicts. If conflicts cannot be resolved by such means, rehabilitation counselors may adhere to the requirements of law, regulations or other governing legal authorities

We will explore the following CRCC Rules of Professional Conduct:

Knowledge of Related Code of Ethics (CRCC Code of Professional Ethics for Rehabilitation Counselors –Section L2d

i. Rehabilitation counselors understand applicable ethics codes from other professional organization or from certification and licensure bodies of which they are members. Rehabilitation counselors are aware that the Code forms the basis for CRCC disciplinary actions, and understand that if there is a discrepancy between codes they are held to the CRCC standards.Organization Conflicts (CRCC Code of Professional Ethics for Rehabilitation Counselors – Section L2f) If the demands of organization with which rehabilitation counselors are affiliated pose a conflict with the Code, rehabilitation counselors specify the nature of such conflicts and express to their supervisors or other responsible officials their commitment to the Code. When possible, rehabilitation counselors work toward change within organization to allow full adherence to the Code. In doing so, they address any confidentiality issues.


Unprofessional conduct

Intimate relationships

Dishonesty

Lack of confidentiality

Obtaining inappropriate potential employment

Common Ethical Violations


If your gut tells you there is a problem, there is!


Competing of conflicting standards to apply

Conflict between what is ethical and what is moral

Application of ethical standards unclear due to complexity of situation

Something prevents clear application of standards

Relationship issues – Dual relationships – Role and boundary problems

Challenges to confidentiality

Cultural issues

Practicing outside level of competency

Common Ethical Dilemmas


You Care About Everything!

Avoid Bad Ideas !

NO! NO! NO! NO!

Bad Idea!

Perception Kills!


Family does not count

You deal in Confidential Information!

Do not bring children or spouses to WORK!

Avoid Bad Ideas Con’t


Even “Colleagues” should be excluded at times.

Confidence is essential to evaluation.

If you need a second opinion, tell the client and get their permission for in person meetings.

Avoid Bad Ideas Con’t.


People handle stress differently and you need to account for that in your evaluations. A very calm and moral person may be an emotional basket case after a stressful situation, and you must work them through that to learn the core issue of the problem

Hold Moral Judgements to the Table


They are worth your time.

Use them to your advantage.

They help you with difficult clients.

They help you with difficult 3rd Parties.

It’s Common Sense and Ethics – Use Them


Board-Certified Disability Management Specialists shall endeavor to place the public interest above their own at all times.Board-Certified Disability Management Specialists shall respect the integrity, dignity, and protect the welfare of those persons or groups with whom they are working.Board-Certified Disability Management Specialists shall always maintain objectivity in their relationships with clients.Board-Certified Disability Management Specialists shall act with integrity and dignity in dealing with other professionals.Board-Certified Disability Management Specialists shall keep their technical competency at a level that ensures their clients will receive the benefit of the highest quality of service the profession can offer. Board-Certified Disability Management Specialists shall honor the integrity of the CDMS credential and respect the limitations placed on its use.Board-Certified Disability Management Specialists shall obey all laws and regulations, avoiding any conduct or activity that could harm others.Board-Certified Disability Management Specialists shall help maintain the integrity of the CDMS Code of Professional Conduct.

Certified Disability Management SpecialistPrinciples


A Board-Certified Case Manager (CCM) will not intentionally falsify an application or other documents.

A Board-Certified Case Manager (CCM) will not be convicted of a felony.

A Board-Certified Case Manager (CCM) will not violate the code of ethics governing the profession upon which the individual’s eligibility for the CCM designation is based.

A Board-Certified Case Manager (CCM) will not lose the primary professional credential upon which eligibility for the CCM designation is based

A Board-Certified Case Manager (CCM) will not violate or breach the Standards for Professional Conduct.

A Board-Certified Case Manager (CCM) will not violate the rules and regulations governing the taking of the certification examination and maintenance of CCM

Certification.

CCM Rules of Professional Conduct


Maintain Records:

Very important

Keep it simple

Build each entry to form a theme

To Accomplish Your Goals:


Be Objective

Focus on the issue

Keep your goals focused to the subject

Look at the realistic potential

GOALS con’t


Maintain dignity and professionalism

It’s not easy

Use it as a fall back

The worst that will happen is that you will buy additional time to objectively evaluate the situation.

Goals Con’t


I must follow the protocols to protect you the client/claimant

I am protecting your information.

I am here to help you.

I have a higher duty.

I must uphold the standards to protect you, so you get the appropriate services.

Use Ethics to your Advantage


This is Why


Provide informed consent.Explain protection procedures.Give the patient a form to sign.Get parental permission for minors.Describe research.Store records safely.Do not release records to any third parties.Protect records at home.Provide records to client.Stay current with counseling ethics and regulations.Be aware of exceptions.Avoid confidential details in discussions with peers.Do not engage in conversations in public.

Goals Con’t


Confidentiality is waived when a client makes threats of suicide or homicide.

Waived when information is disclosed relevant to the abuse of children or the elderly.

Depending on the state you might be required to reveal info to a third party when the client has a life-threatening disease that could be communicated to said third party.

If a court subpoenas records you ask for written consent from your client. If not forthcoming, it is your responsibility to try to limit or prevent the disclosure of records

Exceptions!


When a counselor finds they are in a situation where maintaining a client's confidentiality becomes a problem, consult with colleagues and/or a direct supervisor can help the counselor with appropriate decision-making.

A counselor may also discuss confidentiality concerns with his or her own therapist, so long as they don’t reveal information that may identify the client being discussed

Stay current with counseling ethics and regulations


Spouse(s)

Patricia Ecker (m. 1986; div. 1995);

Jimena Gomez Paratcha (m. 1995; div. 2008)

Partner(s)

Scarlett Sabet (2014–present);

Charlotte Martin (1970-1982);

Lori Maddox (Really & Why?)

Do not acknowledge clients in public.


When dealing with the public, family, clients or non-consulting colleagues change details to protect the client.


Back to Safety


Policyholder Themes

David v. Goliath - the only way to send a message to the insurance company is through a large award.

Themes for your Expert to Promote


California Civil Jury Instructions (CACI) 2330. Implied Obligation of Good Faith and Fair Dealing Explained•To breach the implied obligation of good faith and fair dealing, an insurance company must, unreasonably or without proper cause, act or fail to act in a manner that deprives the insured of the benefits of the policy. It is not a mere failure to exercise reasonable care. However, it is not necessary for the insurer to intend to deprive the insured of the benefits of the policy.

•Courts around the nation may or may not determine expert testimony is needed. Go case by case. Experts may be permitted to establish industry custom and practice or “good faith” claims handling principles

What is “Bad Faith”?California


Can expert testify about policy drafting, that policy language is ambiguous, that exclusions are inconspicuous, or how the policy language should be interpreted and applied to the facts?

Retain the Expert Early - No surprises

Early file review to ensure they are comfortable with your client’s position and can assist in preparing for trial.

Identifying Potential Expert IssuesCoverage Issues


When might I need an expert on claims handling?

Are they required?

See, e.g. Bergman v. USAA, 742 A.2d 1101 (Pa. Super. 1999)(court refused to adopt a blanket rule requiring expert testimony in all cases involving bad faith claims)

Some Basics


District of Colorado barred opinions of plaintiff’s expert on interpretation of homeowner’s policy language regarding replacement cost, and policy ambiguity

Slavin v. Garrison Prop. & Cas. Ins. Co., 2017 WL 2928030 (D. Col. July 10, 2017).

Some BasicsPolicy Interpretation


Northern District of Illinois barred certain opinions which were legal conclusions but allowed other opinions which were not.

Essex Ins. Co. v. The Structural Shop, Ltd. 2017 WL 2224879 (N.D. Ill. May 22, 2017); see also Fox v. Admiral Ins. Co., 2016 WL 6476461 (N.D. Ill. Nov. 2, 2016).

Some BasicsLegal Conclusions


Courts are generally more amenable to testimony on “good faith” claims principles articulated in cases, statutes and regulations•…the Court excluded some of the opinions of the insured’s bad faith expert on a motion in limine.

• the expert cannot testify that the defendant insurer acted in “bad faith” or violated particular statutes, as those are legalconclusions

Kraeger v. Nationwide Mut. Ins. Co., 1997 WL 109582 (E.D. Pa. Mar. 7, 1997).

Some Basics


Courts are generally more amenable to testimony on “good faith” claims principles articulated in cases, statutes and regulations•…the Court excluded some of the opinions of the insured’s bad faith expert on a motion in limine.

But expert can opine, based upon expertise and experience, that defendant insurer had no reasonable basis for its actions

Kraeger v. Nationwide Mut. Ins. Co., 1997 WL 109582 (E.D. Pa. Mar. 7, 1997).

Some Basics


The District of Colorado ruled expert testimony can be taken into account to determine • “the standard of care, if the standard is not within the common knowledge of the ordinary juror”

O’Sullivan v. GEICO Cas. Co., 233 F.Supp.3d 917 (D. Col. 2017).

Some BasicsIndustry Custom and Practice


Insurance policies are contracts, with limits on coverage, yet insurance companies always looks to find coverage as reasonably permitted by contract.

Insurance companies are not perfect; they are human, can make mistakes or misunderstand without being unreasonable;

The insurance policy places duties on both parties; the Insurance company honored the contract more than the insured

The insurance company went to great effort and expense to adjust the claim.

Admit to mistakes/apologize/lessons learned.

Themes for your Expert to PromoteInsurance Company Themes


Be concise - long-winded experts and/or tedious presentations lose the jury and anger them

Graphics, Timelines, Exhibits, PowerPoint and Visual Aids. USE THEM

This is an opportunity for your expert to talk directly to opposing counsel and the opposing party

Make a strong impression

Demonstrate you are prepared to take case to trial

Trial / ADR Presentation


Translation - Boiling


Rapid vaporization of a liquid, which occurs when a liquid is heated to its boiling point, the temperature at which the vapor pressure of the liquid is equal to the pressure exerted on the liquid by the surrounding atmosphere.

Experts: Stick with admissible descriptions and plain English


You Get Samples From Lindt, Why Not From Experts?!


The Result of Boring


This is Prepared


This is not prepared


78

What I do not say?

What Do I Say in Expert Disclosure


Stick with admissible descriptions and use plain English

Sample Disclosures – REVIEW THEM

Experience in the insurance industry

Experience dealing with the specific types of insurance and claims at issue in your case

Education and training

Brevity!!!!!!

What to Consider in Expert Testimony


More than one expert is helpful, but cumulative expert testimony will normally not be allowed

If more than one expert is used, court may preclude one of them unless they offer different perspectives: for example, claims handling vs. underwriting

Rule 403, Federal Rules of Evidence

Some Final PointsWhat to Consider in Proffering or Opposing Expert Testimony


The expert may refer to “the law,” e.g., statutes or regulations if:

they serve as a background for the development of good faith or customary claims practices, or

are the basis from which these good faith claims practices have evolved or

“Substantial Deviation”

Some Final PointsWhat to Consider in Proffering or Opposing Expert Testimony


Know Your Jury


Appearances are deceptive


Dr. Nyce•Was areal physician and successful businessman

•Killed his wife brutally in their Hopewell, NJ mansion

•The police literally followed the evidence to him

Go Beyond Always


Pre-COVID

Consider the Court Room Post-COVID


Yes, my first trial again!


Claims examiners are people with a very specific duty. They process claims they do not write checks. You have the highest duty amongst all the persons who are involved in the claims process. Remember you can be:

Thank you for your time and now for any questions.

Conclusion


Ethical Claims Management

PMTLawFirm.com

March 25, 2021PRESENTED BY

John J. Tambascia, Esquire

Thank You!

ethical claims management

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