How does an adjuster determine if a claim is covered under the policy?

The correct approach for an adjuster to determine if a claim is covered under the policy is to review the policy language and compare it to the details of the claim. This method is foundational in the claims adjustment process, as it involves a systematic analysis of the specific terms, conditions, and exclusions contained within the insurance policy.

By meticulously examining the policy's wording, the adjuster can identify whether the circumstances of the claim fall within the coverage parameters established by the insurer. This includes looking at specific definitions of coverage, limits, deductibles, and any exclusions that may apply. This logical and document-based method is essential for making an informed decision about the acceptability of the claim under the stated policy provisions.

Other methods mentioned, such as contacting the policyholder's attorney, rely on external opinions that may not provide clarity on the policy's actual coverage. Relying on industry standards can aid in forming a general idea about prevailing practices but does not specifically address the unique terms of the policy in question. Evaluating personal experience with similar cases may lead to bias and subjective decision-making rather than a clear, objective assessment based on the policy documentation. Therefore, the most systematic and reliable method is to review the policy language directly in conjunction with the claim details.