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HCA 111: The Claims Environment

Course Description

This course will cover the necessary claims skills employed by the claims representative; the fundamentals of industry quality claims procedures, successful negotiating techniques in claims settlements, the ability to recognize insurance fraud, and ethical obligations.

Prerequisite

  • ENG 101: English Composition 1

Student Learning Outcomes (SLOs)

Upon successful completion of this course, the student will be able to:

  1. Describe and explain insurance and the claims representative’s role.
  2. Describe and explain the principles of insurance.
  3. Describe and explain the claims process.
  4. Develop skill in interpreting communication in order to help build rapport with others to successfully settle claims.
  5. Describe and explain the most successful negotiating technique for claims settlement.
  6. Recognize insurance fraud and practice anti-fraud efforts.
  7. Develop tools to control legal expense in claims management.
  8. Describe and explain good faith claims handling while avoiding allegations of bad faith.
  9. Develop methodology for claims representatives to fulfill their role in meeting claims management.
  10. Describe and explain ethical obligations.

General Education Outcomes (GEOs)

Please check the applicable GEOs for this course, if any, by outcomes at GEO Category Search, or by subject area at GEO Discipline Search.

Course Activities and Grading

Assignments

Weight

Discussion Questions (Weeks 1-7)

30%

Quizzes (Weeks 1, 2, 4 & 5)

20%

Research Paper Due (Week 7)

30%

Final Cumulative Quiz (Week 8)

10%

Research Paper Presentation (Week 8)

10%

Total

100%

Required Textbooks

Available through Charter Oak's online bookstore

  • Popow, Donna J. Claim Handling Principles and Practices. Malvern, PA: American Institute for Chartered Property/Casualty Underwriters/Insurance Institute of America, 2012. ISBN-13: 978-0-89463-569-4

Course Schedule

Week

SLOs

Readings and Exercises

Assignment(s)

1

1, 2, 3, 10

Topics: Claims Fundamentals & Processes

Readings:

    • Claims Handling Principles and Practice (Textbook). Chapter 2, "The Claims Handling Process" and Chapter 3, "Setting Case Reserves and Investigating Claims."
Discussion Questions:
      1. The claims representative should follow a systematic claim handling process that will help to ensure a claim is handled in good faith from start to finish. Please discuss one activity in the Claims Handling Process and expand on its
      2. The claims representative should follow a systematic claim handling process that will help to ensure a claim is handled in good faith from start to finish. Please discuss one activity in the Claims Handling Process and expand on its relevance.

Quiz due this week based on chapter readings.

2

4

Topics: Communication and Claims

Readings:

  • Textbook. Chapter 4, "Documenting Claims."
Discussion Questions:
      1. Discuss the differences between direct and open-ended questions. Provide an example of each and share which type of question is best and why.
      2. There are advantages and disadvantages of recorded statements as compared to written statements that a claims representative must record when processing claims. Based on the chapter readings discuss at least two of each. Which method has the greatest advantage?

Quiz due this week based on chapter readings.

Note: Submit research paper proposed title for approval by Week 3. It should related to course material. See "Learning Activities" Section above.

3

4, 5

Topics: Fraud and the Legal System

Readings:

  • Textbook. Chapter 6, "Dealing with Fraud."
Discussion Questions:
      1. Research and discuss a recent article that involved insurance fraud. Tie in this week's readings into your post.
      2. Claims representatives must be sure to maintain a balance between suspicions of fraud vs. the possibility that a claim is legitimate despite the presence of at least one fraud indicator. Discuss two questions that could help a representative maintain balance during an investigation.

Submit research paper proposed title for approval.

4

6, 7, 10

Topics: Good Faith and Bad Faith Claim Handling

Readings:

  • Textbook. Chapter 9, "Good-Faith Claim Handling."
Discussion Questions:
  1. Discuss the parties of a bad faith claim and provide an example.
  2. Bring in outside research to describe HIPAA and share how this can affect good-faith claim handling.

Quiz due this week based on chapter readings.

Midterm grades posted during Week 4 for Weeks 1-3

5

8, 10

Topics: Ethics and Professionalism

Readings:

  • Textbook. Chapter 1, "The Claim Function and Professional Ethics."
Discussion Questions:
  1. Explain why ethics and professionalism are important to a claim representative.
  2. Describe the ethical and professional dilemmas claim representatives can face.

Quiz due this week based on chapter readings.

6

9, 10

Topic: Claims Management

Readings:

  • Textbook. Chapter 7, "Negotiating Claims."
Discussion Questions:
  1. Describe the negotiation techniques claim representatives should avoid and the reasons those techniques should be avoided.
  2. Describe the four different types of negotiation and which style is generally best suited for use by claim representatives.

7

4

Topic: Litigation Management

Readings:

  • Textbook. Chapter 5, "Communicating Effectively."
Discussion Question:
  1. Given a bad-faith lawsuit against an insured, describe the activities a claim representative would perform to manage the lawsuit.
Research Paper Due

8

1-10

Readings:
  • None
  • Research Paper to be presented to the class during Week 8. Discuss your paper teaching the class. Please do not present the formal paper submitted to me. You all can learn from each other.
  • Cumulative quiz covering chapters 1-7 & 9 in the text.

COSC Accessibility Statement

Charter Oak State College encourages students with disabilities, including non-visible disabilities such as chronic diseases, learning disabilities, head injury, attention deficit/hyperactive disorder, or psychiatric disabilities, to discuss appropriate accommodations with the Office of Accessibility Services at OAS@charteroak.edu.

COSC Policies, Course Policies, Academic Support Services and Resources

Students are responsible for knowing all Charter Oak State College (COSC) institutional policies, course-specific policies, procedures, and available academic support services and resources. Please see COSC Policies for COSC institutional policies, and see also specific policies related to this course. See COSC Resources for information regarding available academic support services and resources.