What does an insurance adjuster do?

The adjuster’s job

After you report a claim, the insurer assigns an adjuster. Their job has three parts:

1. Investigate. Find out what happened, when, and what caused it.
2. Decide coverage. Compare the facts with your policy: what is covered, what is excluded, which limits and deductibles apply, and whether the policy conditions were met.
3. Quantify. Determine the cost of repairing or replacing what was damaged, and authorise payment.

They also coordinate the people involved: restoration contractors, engineers, cause-and-origin investigators, contents specialists and you.

Kinds of adjuster

Staff adjuster. An employee of your insurance company.

Independent adjuster. Works for an adjusting firm hired by the insurer, common when the insurer has no staff nearby, after large regional events, or for specialised losses. Independent adjusters in Ontario are licensed by the Financial Services Regulatory Authority of Ontario. Despite the name, they act on behalf of the insurer.

Public adjuster. Hired and paid by you, to prepare and negotiate your claim. They are far less common in Canada than in the United States, and are typically paid a percentage of the settlement. They can be worth considering on a large, complex or disputed loss. Check licensing and read the fee agreement closely.

Appraiser. Assesses the value of damage, often for vehicles and sometimes for property.

Your broker or agent is not an adjuster. They sold you the policy and can explain it, help you report the claim and speak up for you if things stall.

Whose side are they on?

Staff and independent adjusters are paid by the insurer. They also have a duty to deal with you fairly. Insurers in Ontario must follow rules against unfair or deceptive practices in handling claims, and Canadian courts have long held that insurers owe policyholders a duty of good faith.

In practice, most adjusters want to settle legitimate claims correctly and close the file. Their caseloads are heavy. Clear information from you makes it easier for them to say yes.

What happens at the first contact

• They confirm the basic facts and your contact details
• They explain the coverage that appears to apply and your deductible
• They ask what emergency steps have been taken and may arrange a contractor
• They ask whether the home is liveable and explain additional living expenses if it is not
• They arrange an inspection

Ask them:

• What is my claim number, and what is the best way to reach you?
• Which coverages, limits and deductibles apply?
• What do you need from me, and by when?
• Is there anything I should not do or throw away?
• Can I get an advance for immediate expenses?
• What are the next steps and the likely timing?

The inspection

The adjuster, or someone on their behalf, looks at the damage, takes photographs and measurements, and talks to you and the contractor. For smaller claims, this may be done from photographs and the contractor’s report.

To prepare:

• Have your photographs and video from the day of the loss
• Keep the failed part, or the item that caused the fire, where it is if possible
• Have your list of damaged belongings started
• Have receipts for emergency work and expenses
• Point out everything affected, including areas that are easy to miss

After a fire, an origin and cause investigator may examine the scene, separately from the fire department. Do not disturb the area of origin until you are told you can.

What they may ask for

• Photographs and receipts
• A contents list
• Reports from the plumber, roofer or electrician
• Maintenance records, where the cause involves wear or upkeep
• Proof of ownership or value for expensive items
• A recorded or written statement
• A signed proof of loss
• In some cases, an examination under oath, which the policy conditions allow for. If this is requested, consider getting legal advice.

You have a duty under the policy to cooperate and to be truthful. You are also entitled to ask why something is needed.

Working with the adjuster

• Be accurate. If you do not know something, say so. Do not guess.
• Be prompt. Delays in sending documents are the commonest cause of slow claims.
• Put things in writing. After a phone call, send a short email confirming what was agreed.
• Keep a diary of contacts and a folder of documents.
• Ask for the estimate and read it. Query anything missing.
• Get approvals in writing for anything significant: accommodation, storage, the scope of repairs.
• Stay civil. It helps.
• Do not sign a final release until you understand what it covers and are satisfied the claim is complete.

The adjuster and your contractor

The contractor writes an estimate. The adjuster reviews it, often with the same estimating software, and they settle on a scope and price. Differences are normal and are usually resolved by going through the items. Your contractor’s documentation, such as moisture maps, photographs and drying logs, is what supports the scope. You should be kept informed and are entitled to see the agreed figures.

If the adjuster is slow or you disagree

1. Ask the adjuster, in writing, for the reason and the policy wording relied on.
2. Ask to speak to their manager.
3. Ask your broker to step in.
4. Use the insurer’s complaint process and its complaint liaison officer.
5. Take it to the General Insurance OmbudService once you have the insurer’s final position.
6. For disputes about the amount, ask about the appraisal process under the Insurance Act.
7. For significant sums, get legal advice early, because time limits apply.

See water damage claim denied in Ontario.

After a catastrophe

When a storm or flood hits a whole region, insurers bring in adjusters from elsewhere and work through claims in order of severity. Expect a delay before your inspection. Do not wait for it to protect your property. Carry out and document emergency work, keep the receipts, and keep your phone on.

More: fire damage restoration and water damage restoration.