Hawaii Claims Adjuster Insurance Exam

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Here are 14 in-depth Q&A study notes to help you prepare for the exam.

Explain the concept of “bad faith” in the context of Hawaii insurance claims adjusting, detailing specific examples of adjuster actions that could be considered bad faith under Hawaii Revised Statutes (HRS) § 431:13-103.

“Bad faith” in Hawaii insurance claims adjusting refers to an insurer’s unreasonable denial or delay in paying a legitimate claim. HRS § 431:13-103 outlines unfair claim settlement practices, which can constitute bad faith. Examples include: knowingly misrepresenting policy provisions, failing to acknowledge and act promptly upon communications regarding claims, failing to adopt and implement reasonable standards for the prompt investigation of claims, refusing to pay claims without conducting a reasonable investigation based upon all available information, failing to affirm or deny coverage of claims within a reasonable time after proof of loss requirements have been completed, and not attempting in good faith to effectuate prompt, fair, and equitable settlements of claims in which liability has become reasonably clear. An adjuster who consistently undervalues claims, ignores evidence supporting a claimant’s position, or delays payment without justification could be found to be acting in bad faith. The burden of proof lies with the claimant to demonstrate the insurer’s actions were unreasonable.

Describe the requirements for maintaining adjuster licensing in Hawaii, including continuing education requirements, and explain the potential consequences of failing to meet these requirements as outlined in Hawaii Administrative Rules (HAR) Title 16, Chapter 96.

To maintain an adjuster license in Hawaii, licensees must comply with continuing education (CE) requirements as stipulated in HAR Title 16, Chapter 96. This includes completing a specified number of CE credit hours during each license renewal period. The exact number of hours and any specific course requirements (e.g., ethics, law updates) are detailed in the regulations. Failure to meet these CE requirements can result in the license not being renewed, suspension, or even revocation, depending on the severity and frequency of the non-compliance. Licensees are responsible for tracking their CE credits and ensuring timely submission of proof of completion to the Hawaii Insurance Division. Additionally, adjusters must notify the Insurance Division of any changes in their contact information or any disciplinary actions taken against them in other jurisdictions.

Explain the concept of “proximate cause” in the context of Hawaii insurance claims, and provide an example of a situation where establishing proximate cause would be critical to determining coverage under a property insurance policy.

Proximate cause, in Hawaii insurance law, refers to the primary and efficient cause that sets in motion a chain of events leading to a loss. It’s the direct or immediate cause, without which the loss would not have occurred. Establishing proximate cause is crucial for determining whether a loss is covered under an insurance policy. For example, consider a property insurance policy covering wind damage. If a hurricane causes a tree to fall on a house, the wind is the proximate cause of the damage. However, if the tree was already weakened by termite infestation and the wind merely accelerated its fall, the termite damage might be considered the proximate cause, potentially leading to denial of coverage if termite damage is excluded under the policy. The adjuster must thoroughly investigate the sequence of events to determine the true proximate cause.

Discuss the implications of Hawaii’s “no-fault” auto insurance law (HRS Chapter 431:10C) on the claims adjusting process, specifically addressing Personal Injury Protection (PIP) benefits, and the circumstances under which a claimant can pursue a tort claim against a negligent driver.

Hawaii’s “no-fault” auto insurance law (HRS Chapter 431:10C) significantly impacts the claims adjusting process. Under this law, individuals injured in auto accidents are generally entitled to Personal Injury Protection (PIP) benefits from their own insurance policy, regardless of fault. PIP benefits cover medical expenses, lost wages, and other related costs, up to the policy limits. The claims adjuster’s role involves verifying the claimant’s eligibility for PIP benefits, assessing the reasonableness and necessity of medical treatment, and processing payments promptly. However, a claimant can pursue a tort claim (lawsuit) against a negligent driver under specific circumstances, such as when their medical expenses exceed the PIP limit, or if they have suffered permanent disfigurement, significant permanent loss of use of a body part, or death. The adjuster must understand these exceptions to determine whether a tort claim is likely and to coordinate with legal counsel if necessary.

Explain the concept of “subrogation” in insurance claims adjusting, and describe the steps an adjuster would take to pursue subrogation rights on behalf of an insurer in Hawaii, referencing relevant legal principles.

Subrogation is the legal right of an insurer to pursue a third party who caused a loss to the insurer’s policyholder, in order to recover the amount of the claim paid. In Hawaii, an adjuster pursuing subrogation rights on behalf of an insurer would first need to confirm that the policy grants the insurer subrogation rights. Then, the adjuster would investigate the accident to determine if a third party was negligent and caused the loss. This involves gathering evidence such as police reports, witness statements, and expert opinions. The adjuster would then notify the responsible third party (or their insurer) of the insurer’s subrogation claim and demand reimbursement. If the third party refuses to pay, the insurer may file a lawsuit to enforce its subrogation rights. The adjuster must be familiar with Hawaii’s statutes of limitations for various types of claims to ensure the subrogation claim is filed within the prescribed timeframe. The principle of unjust enrichment underlies subrogation, preventing the wrongdoer from escaping liability and the insured from receiving double recovery.

Describe the process for handling a claim involving a “reservation of rights” in Hawaii, and explain the adjuster’s responsibilities to the insured in such a situation, referencing relevant case law or statutes.

A “reservation of rights” in Hawaii occurs when an insurer investigates a claim while simultaneously informing the insured that coverage may not apply. This allows the insurer to investigate the claim without waiving its right to later deny coverage. The adjuster’s responsibilities in this situation are crucial. First, the adjuster must clearly and unequivocally communicate the reservation of rights to the insured in writing, specifying the policy provisions that may preclude coverage and the reasons for the insurer’s concerns. The adjuster must conduct a thorough and impartial investigation, keeping the insured informed of the progress. The adjuster must also avoid any actions that could prejudice the insured’s rights or create an estoppel. If the insurer ultimately denies coverage, it must do so in good faith and provide a reasonable explanation for the denial. Failure to properly handle a reservation of rights can expose the insurer to claims of bad faith. Relevant case law in Hawaii emphasizes the insurer’s duty of good faith and fair dealing in handling claims, even when coverage is uncertain.

Explain the concept of “betterment” in property insurance claims adjusting, and describe how an adjuster should handle a situation where repairs to damaged property result in a betterment to the property’s value in Hawaii.

“Betterment” in property insurance refers to improvements or enhancements to damaged property that increase its value beyond its pre-loss condition. In Hawaii, insurance policies typically aim to restore the property to its condition immediately before the loss, not to provide a windfall to the insured. When repairs result in betterment, the adjuster must carefully assess the extent of the betterment and determine how to fairly compensate the insured. Generally, the insured is responsible for paying the portion of the repair cost that represents the betterment. For example, if an old roof is replaced with a new, higher-quality roof, the insured may be required to pay the difference in cost between a like-kind replacement and the upgraded roof. The adjuster should clearly explain the concept of betterment to the insured and document the calculations used to determine the insured’s share of the repair costs. Transparency and clear communication are essential to avoid disputes.

Explain the concept of “bad faith” in the context of Hawaii insurance claims adjusting, detailing specific actions that could constitute bad faith and referencing relevant sections of the Hawaii Revised Statutes (HRS) and Hawaii Administrative Rules (HAR).

“Bad faith” in Hawaii insurance claims adjusting refers to an insurer’s unreasonable denial or delay in paying a legitimate claim. It arises when an insurer acts unfairly or deceptively in handling a claim. Specific actions that could constitute bad faith include: misrepresenting pertinent facts or policy provisions relating to coverage; failing to acknowledge and act reasonably promptly upon communications with respect to claims; failing to adopt and implement reasonable standards for the prompt investigation of claims; refusing to pay claims without conducting a reasonable investigation based upon all available information; failing to affirm or deny coverage of claims within a reasonable time after proof of loss requirements have been completed; not attempting in good faith to effectuate prompt, fair and equitable settlements of claims in which liability has become reasonably clear; compelling insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insureds. HRS § 431:13-103 outlines unfair claim settlement practices, and HAR Title 16, Chapter 121 provides further details on prohibited conduct. An insurer found to have acted in bad faith may be liable for compensatory and punitive damages.

Describe the process for handling a claim involving a third-party claimant in Hawaii, including the adjuster’s responsibilities regarding investigation, communication, and settlement negotiations, with reference to relevant Hawaii case law regarding duty of care.

When handling a claim involving a third-party claimant in Hawaii, the adjuster must conduct a thorough investigation to determine liability and damages. This includes gathering evidence, interviewing witnesses, and reviewing police reports. The adjuster has a duty to communicate clearly and promptly with the claimant, providing updates on the claim’s status and explaining the reasons for any delays. Settlement negotiations must be conducted in good faith, with the goal of reaching a fair and equitable resolution. Hawaii case law, such as Best Place, Inc. v. Penn America Ins. Co., establishes that insurers owe a duty of good faith and fair dealing to both their insureds and, to some extent, third-party claimants. This duty requires the adjuster to act reasonably and avoid actions that could prejudice the claimant’s rights. The adjuster must also be aware of Hawaii’s comparative negligence laws, which may affect the amount of damages recoverable by the claimant. Failure to adhere to these standards can expose the insurer to liability for bad faith.

Explain the concept of “concurrent causation” in the context of property insurance claims in Hawaii, and how it impacts the adjuster’s determination of coverage, referencing relevant Hawaii Supreme Court decisions.

“Concurrent causation” arises when a loss is caused by two or more independent perils, at least one of which is covered by the insurance policy and at least one of which is excluded. In Hawaii, the “efficient proximate cause” rule generally applies, meaning that if the covered peril is the efficient proximate cause of the loss, the loss is covered even if an excluded peril contributed to the loss. However, the Hawaii Supreme Court has addressed this issue in cases like Sentinel Ins. Co. v. First Ins. Co. of Hawaii, clarifying the application of the efficient proximate cause rule. The adjuster must carefully analyze the sequence of events and determine which peril was the dominant or efficient cause of the loss. If the covered peril was the efficient proximate cause, the claim should be covered, even if an excluded peril played a role. The burden of proof is typically on the insured to demonstrate that a covered peril was the efficient proximate cause of the loss.

Describe the requirements for maintaining proper documentation and record-keeping in claims adjusting in Hawaii, including the types of documents that must be retained and the retention period, referencing relevant sections of the Hawaii Administrative Rules (HAR).

Maintaining proper documentation and record-keeping is crucial for claims adjusting in Hawaii. Adjusters must retain all documents related to a claim, including the policy, claim forms, investigation reports, correspondence, settlement agreements, and payment records. These documents must be organized and readily accessible for review by the insurer, regulators, or other authorized parties. HAR Title 16, Chapter 121 outlines specific requirements for claims handling and record-keeping. Generally, claim files must be maintained for a minimum period of three years from the date of final disposition of the claim, or longer if required by law or the insurer’s internal policies. The records must be sufficient to allow for a complete audit of the claim handling process. Failure to maintain adequate documentation can result in penalties and disciplinary action.

Discuss the ethical considerations for claims adjusters in Hawaii, including potential conflicts of interest and the adjuster’s duty to act with honesty, integrity, and impartiality, referencing the Code of Ethics for Insurance Professionals.

Claims adjusters in Hawaii must adhere to a high standard of ethical conduct. This includes acting with honesty, integrity, and impartiality in all dealings with insureds, claimants, and other parties. Adjusters must avoid conflicts of interest, such as representing both the insurer and the insured in the same claim. They must also disclose any potential conflicts of interest to all parties involved. The Code of Ethics for Insurance Professionals provides guidance on ethical conduct for adjusters. This code emphasizes the importance of acting in the best interests of the client, providing accurate and truthful information, and avoiding any actions that could harm the reputation of the insurance industry. Adjusters must also comply with all applicable laws and regulations. Violations of ethical standards can result in disciplinary action, including suspension or revocation of the adjuster’s license.

Explain the process for resolving claim disputes in Hawaii, including mediation, arbitration, and litigation, and the circumstances under which each method is appropriate, referencing relevant sections of the Hawaii Revised Statutes (HRS) regarding dispute resolution.

Hawaii offers several methods for resolving claim disputes, including mediation, arbitration, and litigation. Mediation involves a neutral third party who helps the parties reach a mutually agreeable settlement. It is a voluntary process and is often used in cases where the parties are willing to negotiate but need assistance in reaching a compromise. Arbitration involves a neutral third party who hears evidence and makes a binding decision. It is a more formal process than mediation and is often used in cases where the parties have agreed to arbitrate their disputes. Litigation involves filing a lawsuit in court and having a judge or jury decide the case. It is the most formal and adversarial method of dispute resolution. HRS Chapter 658A governs arbitration in Hawaii. The choice of dispute resolution method depends on the specific circumstances of the case, including the complexity of the issues, the amount in dispute, and the parties’ willingness to negotiate.

Describe the specific requirements for handling claims involving Uninsured Motorist (UM) and Underinsured Motorist (UIM) coverage in Hawaii, including the steps the adjuster must take to protect the insured’s rights and the potential for subrogation, referencing relevant sections of the Hawaii Revised Statutes (HRS) regarding motor vehicle insurance.

Handling UM/UIM claims in Hawaii requires specific attention to detail. The adjuster must first determine whether the at-fault driver was uninsured or underinsured, as defined by HRS § 431:10C-301. The adjuster must then investigate the accident to determine liability and damages. The insured must provide notice to their UM/UIM carrier before settling with the at-fault driver’s insurance company, if any, to protect the carrier’s subrogation rights. The adjuster must also advise the insured of their right to pursue a claim against their own UM/UIM policy. If the insured’s damages exceed the at-fault driver’s policy limits (in the case of UIM), the adjuster must evaluate the claim and negotiate a settlement with the insured. The UM/UIM carrier has the right to subrogate against the at-fault driver to recover any amounts paid to the insured. Failure to properly handle UM/UIM claims can expose the insurer to liability for bad faith.

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