Checking a claim against policy cover

To check a claim against cover, find the insuring clause that matches the reported cause of loss, read it with every endorsement in force on the date of loss, and note the exclusions, the excess or sublimit and any conditions. The checking is document work. The decision on the claim stays with your adjuster.

What a coverage check involves

A coverage check starts from the first notice of loss and ends with a list of wording the adjuster can rely on. For each claim it covers the same points.

• The wording in force. The policy and every endorsement that amends it, as they read on the date of loss.
• The insuring clause. The section that grants cover for the cause the claim reports, such as a sudden escape of water.
• Exclusions and conditions. Anything that removes or limits cover, and any condition the insured had to meet, such as a notice period.
• The excess and sublimits. These are often set by endorsement rather than in the base policy, so the base policy alone gives the wrong figure.
• The facts in the claim file. The first notice, adjuster notes and loss reports, and which of them the wording depends on.

Why the check takes time by hand

The documents sit in different places. The policy is in one system, the endorsements in a folder or an email, and the loss report is a scan. The adjuster opens each, matches the cause of loss to a clause, then checks whether an endorsement changed the clause or the excess. For one claim that is manageable. Across a queue of claims the same reading repeats.

The risk is a missed endorsement. A base policy may set one excess and an endorsement may set another. Reading the base policy alone gives an answer that was once right and is now wrong.

How the engine checks a claim against cover

The engine links each claim to the policy it cites and to the endorsements that amend that policy. When you ask whether a claim falls within cover, it finds the clause that applies and quotes it with the page it came from. It quotes the endorsement that sets the excess beside the base clause. Each line opens the document it came from.

Routine checks run on their own, so the adjuster starts from a list of found wording. A passage has to be found in your documents before it is written as an answer. If it cannot be found, it is flagged. A page it cannot read, such as a faint scan, goes to a person rather than being guessed at.

Does the water damage claim fall within cover, and what is the excess? 5 documents · 1 for you

Found

Property policy, Section 2 loss caused by the sudden escape of water from any fixed tank, apparatus or pipe Section 2, Escape of water

Found

Endorsement 5 the Excess applying to Section 2 is ten thousand dollars ($10,000) each and every loss Endorsement 5, amending Section 2

For you

Scanned loss report

Page 3 is too faint to read. It has gone to a person.

The wording that applies is found. The decision on the claim is your adjuster's.

Invented example The claim, policy and figures in this example are invented. No client material appears anywhere on this site.

What the engine does not do

It does not accept, reject or reserve a claim, and it does not send anything to the insured. It finds and quotes wording, links it to its source and flags what it could not read. Your adjuster decides the claim, and a reviewer signs off on any draft before it goes out.

Questions

When a shared product is the better fit

If your claims run on standard forms and a claims system already holds the policy terms for each claim, that system may serve you better than a firm-owned engine. We will say so on the first call.

See it on your own claim files

Pick a closed claim your team knows well, with an endorsement that changed the excess. After an NDA, we build a prototype on your own documents, at a fixed investment agreed before work starts, and you can check its answer against what your adjuster found.