Claims Handling Fundamentals

Course Overview

Claim Handling Fundamentals is a foundational course designed to equip learners with a solid understanding of how insurance claims are managed, the purpose and structure of claims departments, and the professional principles that guide claims personnel. Drawing from core insurance operations, the course explores the dual mandate of the claims function—fulfilling the insurer’s promise to policyholders and supporting the insurer’s profit goals. Learners are introduced to the distinctions between first-party and third-party claims, the responsibilities of claims representatives, and the broader role of claims data in underwriting, marketing, pricing, and financial performance.

The course also examines how insurers organize claims departments, the diverse categories of claims personnel—including staff adjusters, independent adjusters, TPAs, producers, and public adjusters—and the operational relationships among them. Additionally, the curriculum provides insight into performance measurement tools such as loss ratios, best practices, claims audits, and customer satisfaction processes, showing how these mechanisms ensure fairness, efficiency, regulatory compliance, and overall profitability.

Through applied concepts, real-world examples, and structured guidance, this course prepares participants to understand the claims function as a critical pillar of insurance operations and a key determinant of customer experience, insurer reputation, and long-term business sustainability.

Learning Objectives

Upon successful completion of all the modules in this course, you should be able to:

  • Explain the primary goals of the claims function—keeping the insurer’s promise and supporting the insurer’s profit objectives—within the insurance value chain;
  • Differentiate between first-party and third-party claims, including how each type of insurance responds to loss events and pays claimants;
  • Describe the concept of indemnity and fair claims handling, and explain how claim representatives promote peace of mind for policyholders and claimants;
  • Identify and explain the structure of claims departments, including home-office functions, regional offices, and branch-level operations;
  • Recognize the different types of claims personnel—staff adjusters, field adjusters, independent adjusters, third-party administrators, producers, and public adjusters—and describe their respective roles;
  • Analyze how insurers use claims information to support underwriting, marketing, pricing, and financial management;
  • Explain the significance of loss ratios as a profitability measure and evaluate how claims handling practices influence insurer financial results;
  • Assess operational and financial challenges within claims departments, including expense control, vendor management, and managing inflated or fraudulent claims;
  • Evaluate quality assurance mechanisms in claims management, including best practices, claims audits, and customer satisfaction monitoring; and
  • Apply the principles of good-faith claims handling to ensure timely, equitable, and defensible settlement decisions that uphold both customer trust and insurer profitability.

Module 1: Course Overview

Module 2: Goals of the Claims Function

Module 3: Claims Department Structure, Personnel, and Performance

Module 4: Importance of Ethics and Professionalism for Claim Representatives

Module 5: Recognizing the Ethical and Professional Concerns Claim Representatives Face

Module 6: Codes of Ethics and Quality Claim Practices

Module 7: Case Study - Ethical and Professional Dilemmas of Claim Representatives

Module 8: Overview of the Claim Handling Process

Module 9: Claim Handling Process - Acknowledging the Claim and Identifying the Policy

Module 10: Claim Handling Process-Contacting the Insured

Module 11: Investigating and Documenting the Claim

Module 12: Bases for Legal Liability

Module 13: Determining the Cause of Loss, Liability, and the Loss Amount

Module 14: Claim Handling Process-Concluding the Claim

Module 15: Establishing a Case Reserve

Module 16: Reserving Case Study

Module 17: Negotiating Claims- Styles of Negotiation

Module 18: Claim Negotiation Process

Module 19: Claim Negotiation Variables

Module 20: Overview of Claim Negotiation Techniques

Module 21: Claim Negotiation Techniques to be Avoided

Module 22: Common Pitfalls in Claim Negotiation

Price: $175

This Course includes:

   Text-based content

   4 Weeks