Inside the Claim Review: What Adjusters Actually Check

Many people assume when they file a claim that an adjuster’s job is to find a reason to deny the claim.  This couldn’t be further from the truth.  In all honesty, an adjuster’s job is 1) to find out what happened; 2) to determine what coverages apply; and 3) to apply the coverages consistently, fairly and in good faith. As your claim progresses, you will notice that your adjuster is taking steps to ensure that this process continues as smoothly as possible, clearly all the while eliminating misunderstandings and uncertainty to the extent possible. When you are clear about what your adjuster is looking for it can help you avoid delays and get your claim resolved more quickly.

Step 1 - Coverage

Before the investigation of fault or anything else, an adjuster will be looking to confirm coverage. They want to confirm what coverages could apply to the loss to ensure that the claim will continue. There are three key questions they will look at first:

·        Does coverage apply to this loss?  Was the policy active as of the date of the accident, and is this specific driver and vehicle insured as of that date?

• Is this specific type of loss covered? Is there comprehensive, collision or uninsured motorist property damage coverage available? Depending on the type of accident, they will be looking to confirm that the specific type of coverage is active on the policy.
• Do any exclusions apply? Has this driver been excluded from the policy? Was it being driven for the wrong purpose and is therefore not covered (were you using the vehicle for business purposes and filing a claim under a personal insurance policy?)?

It is important that this step be completed thoroughly and correctly. If it is determined later in the claim that coverage doesn’t apply, the claim will be stopped, all services will be cancelled and the parties may end up paying out of pocket for any services that were rendered because the coverage no longer applies.

Once they have been able to confirm coverage, your adjuster will then go on to setting up your services, repairs, rental or any other coverages that apply under your first party coverage and continuing with the liability investigation.

Step 2 – What happened?

Once coverage has been confirmed, your adjuster will then turn to establishing what happened.  They will be looking to establish a clear timeline of the accident. They will first look at the facts of loss as written when you reported the claim. This is when you tell the story, either online (if you are reporting digitally) or to the first notice of loss team member if you call in. You will then be contacted to provide a recorded statement. A recorded statement is a recording where an adjuster will ask you details about the accident (where, when, types of vehicles involved) and will ask you to describe how the accident happened. 

If you are unable to provide a recorded statement, your adjuster will request a written statement an will likely send a list of questions for you to answer. Once all the statements have been gathered from all of the parties involved (including passengers and witnesses), your adjuster will turn to reviewing the other evidence provided.  This will typically includes photos, videos and police reports.

Your adjuster is looking to see whether the story makes sense.  Do the different pieces of the story fit? Are there contradictions? Do the stories of each party support or contradict each other? Are the details consistent for each party?

You want to make sure you are honest and complete. Make sure you state any details you remember and make the story as complete as possible. Sounding right may sound like the goal, but believe it or not, adjusters can generally tell when the story has been rehearsed or changed. Remember they take many statements in a day and when a statement sounds off it can ring alarm bells!

Step 3 – When and how did the damage occurred?

Once they have a complete version of the story, the adjuster will move on to evaluating the damages on all vehicles involved. They will review photos and videos of the damage, review how and where the accident happened and look at what type of damage was caused.  Are there scrapes and dents or is the vehicle crushed? Is there paint transfer? How high is the damage on the vehicle? In which direction is the damage moving?

They will evaluate the damages to see if they are consistent with the facts of the accident as reported. They will also look to see that the damage could have been caused by this specific incident. They will look to see instances of rust or aging on the damage to ensure that the damages being claimed are not from an earlier accident.

If the adjuster notices that damage being claimed is potentially prior damage, typically an estimator or an appraiser will be requested so that the damage can be evaluated more closely. This can slow down the evaluation and repair of damages, since damage that is determined not to be associated with the accident will not be covered by the current claim and will be specifically excluded.

One of the easiest ways to keep your claim moving in this phase of the claim evaluation process it ensure that you provide clear photos of the damage.  You want to take pictures far enough that it is clear what part or parts of the vehicle were impacted and close enough that what kind of damage was caused is also visible.

Step 4 – Who is at fault?

The next step for the adjuster is to determine who is at fault. Here is where they will evaluate the statements of parties involved and witnesses, review videos, study the location of the accident and map it out and review police reports if available.

Remember that the adjuster will look at the traffic laws, study the accident and how it occurred and will then apply those rules to the accident. Fault is not always obvious and statements from the different parties are often conflicting and contradictory. Fault will be applies based on the accident as understood by the adjuster and there are many cases where the there is no additional evidence and a claim is found to be word versus word. In those cases fault cannot be concluded definitively and each insurance company involved will deny liability for their driver.

Step 5 - Prior Claims, Prior Damage, and Vehicle History

By this point your adjuster has been able to determine which coverages apply, what happened and how, evaluate the damage involved and assigned liability.  Now they will move on to reviewing the vehicle history.  They will confirm prior reported damage for the vehicle, any prior claims on the vehicle (especially if recent) and the condition of the vehicle prior to the loss.

Adjusters are confirming that the damage is related to the current claim so that they can pay what is owed for the claim. They will be looking to eliminate damage that is unrelated or prior to the current loss. Each claim will cover only damage related to that specific set of circumstances.  Be clear and honest about what damage was caused by the accident to prevent delays, investigations and possible denial.

Step 6 – Your policy limits and deductibles: Why Some Delays Feel Unfair

When a claim slows down because of a deductible, a limit, or a rule, it can feel frustrating. Especially when you’ve done everything right. But in many cases, the delay isn’t about judgment. It’s about structure. Adjusters don’t get to ignore certain parts of the policy, even if they want to help.

Here are the most common friction points in a claim:

1. Deductibles

Your deductible is the portion you agreed to pay before coverage applies.

If damage is close to or below the deductible amount, that can slow decisions because:

·        Repairs may not exceed the deductible

·        Additional review may be required

·        You may decide not to move forward

It’s not a penalty. It’s part of the policy contract.

2. Coverage Limits

Every policy has limits — the maximum the company will pay.

Delays can happen when:

·        Damage exceeds the coverage limit

·        Rental time reaches the daily or total cap

·        Multiple claims compete against one limit

Adjusters cannot exceed these limits, even if they sympathize with the situation.

3. State Rules

Insurance is regulated at the state level.

Some states require:

·        Specific timelines

·        Liability confirmation before payment

·        Certain documentation standards

Adjusters must follow those rules exactly.

Many drivers assume adjusters can “make exceptions.”

In reality:

·        Policies are contracts

·        Payments must be consistent across customers

·        Decisions are audited and documented

An adjuster who ignores rules isn’t being helpful — they’re risking compliance issues and potential regulatory penalties.

Conclusion

Adjusters are not looking to judge or trick you when they evaluate your claim. They are looking to pay what is owed for your claim based on the coverage afforded by your policy. They will try to be fair and apply the coverage where and how they are able.

To ensure that your claim moves smoothly make sure that you provide your adjuster with the information they are looking for. Make sure you report your claim promptly and be honest and complete. Take good photos of all vehicles involved and be prompt in your responses. Your adjuster is usually communicating to move the claim forward and the faster you respond, the better. And always remember, if you get confused, don’t hesitate to ask questions.