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Consulting expert

Claims and reserve auditing.

Audits of claim files and held reserves for carriers, receivers, and risk retention groups, delivered as an audit, a study, or an adjudication rather than as testimony.

Reserve adequacy studies Claim audits and file scoring Estate claim adjudication and audits

About this practice area

Why claims and reserves are audited.

A claim reserve is an insurer’s estimate of what it will ultimately pay on a claim. Reserves are frequently the largest liability on a carrier’s balance sheet and drive an insurer’s financial statements and its solvency, so regulators, auditors, reinsurers, acquirers and, when a company fails, receivers all need to know whether they are adequate.

Claim audits test how claims are actually being handled, usually by examining a random sample of files against the company’s own standards and the industry’s: whether coverage was confirmed, the investigation was timely, the reserve was set and revised properly, payments were accurate and the file was documented. Reserve adequacy studies compare held reserves with what the files support.

In an insolvency, each claim filed against the estate must also be evaluated and adjudicated before the estate can pay creditors and close. Audits and studies of this kind are typically delivered as a report or adjudication rather than as testimony, though the same analysis can later support an expert opinion.

A claim-audit score sheet for a random sample of five files: rows receiving glowing checkmarks, one file flagged with an amber X, the sheet signed off at the foot

Sub-categories

Audits, studies, and adjudications.

Reserve adequacy studies

Whether the reserves held match what the files support, case by case and in total.

View Reserve adequacy studies →

Claim audits and file scoring

Random-sample file scoring that measures how a claims operation is performing against its own standards and the industry’s.

View Claim audits and file scoring →

Estate claim adjudication and audits

Evaluating, adjudicating, and auditing the claims filed against an insurer in liquidation.

View Estate claim adjudication and audits →

Engagements

Matters handled.

Where the same work later supported an expert opinion, the matter also appears under Testifying Expert.

Testifying expert · Report, Deposition, Trial

Three-month trial over a failed insurer’s directors and outside auditor

$2Bplea in the case

265claim files scored

800+page report

Receiver’s expert

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Engaged by the Florida Department of Financial Services as an expert to review the claims practices of an insurance entity in Receivership, in a case for damages against the Directors and Officers of the insurer as well as their outside auditor. This required analysis of issues such as corporate governance, claim reserving, communication with claimants, and adherence to fair claims practice rules & file documentation standards for claims. The plea in the case was for $2 billion. Mr. Bingham testified during the three-month trial. Mr. Bingham and his team scored 265 files and completed a report of over 800 pages.

Circuit Court of the Second Judicial Circuit, Leon County, Florida

Also listed under: Testimony for Receivers and Regulators · Carrier claims-practice reviews & audits · Receiver’s expert in suits against officers and professionals · Testimony record

Testifying expert · Report, Deposition

Errors-and-omissions suit against a failed risk retention group’s directors, auditors, and actuaries

2-daydeposition

Finalreport issued

Settledafter the deposition

Receiver’s expert

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Retained by the Special Deputy Liquidator for a South Carolina domiciled medical malpractice risk retention group in Liquidation. The Special Deputy Liquidator is suing the company’s former directors and officers, accountants, auditors, and actuaries for errors and omissions. Mr. Bingham has completed an extensive review of the company’s claim files and information management systems and has issued a final report. Upon completion of Mr. Bingham’s two day deposition the cases settled on terms favorable to the Receiver and the South Carolina Department of Insurance.

Court of Common Pleas, Fifth Judicial Circuit, Richland County, South Carolina

Also listed under: Testimony for Receivers and Regulators · Receiver’s expert in suits against officers and professionals · Reserve studies for carriers · Claims Handling Review · Testimony record

Testifying expert · Report

TPA suit over a workers compensation deductible recovery: random 52-file audit

100files reviewed, 52 selected at random

100+page rebuttal report

379citations, 23 exhibits

Defense of TPAs, agencies, and counsel

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Retained by counsel representing a third-party administrator being sued for negligence and breach of contract. Allegations against the third-party administrator included erroneous coverage interpretation and application as well as conducting an untimely investigation and inadequate reserving. The dispute arose from a workers compensation carrier’s recovery action against a policyholder for paid benefits subject to the policy’s deductible. GIC selected at random 52 files for review and utilized a proprietary score sheet to aggregate the results. In all, 100 files were reviewed. GIC authored a rebuttal report of over 100 pages containing 379 citations and 23 exhibits.

Also listed under: Defense of TPAs, Agencies, and Counsel · Claims Handling Review · Expert Testimony · Testimony record

Consulting

Two-year run-off plan for all claims activity

2-yearoperational plan

10,000sof claims evaluated and paid

Reinsurance and run-off

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Developed a two-year operational plan which directed all claims activities including the evaluation, adjudication, and payment of tens of thousands of claims and the collection of the commensurate reinsurance.

Also listed under: Carrier claims-practice reviews & audits · Reinsurance collections and run-off operations

Testifying expert · Report, Trial

Reserve studies

Almost everyline of business

Trialtestimony in receivership proceedings

Reserve studies

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Performed multiple reserve adequacy studies for property & casualty, life & accident, auto warranty, workers compensation carriers, professional liability, asbestos & environmental, and more. Reports and trial testimony was provided in contested receivership proceedings.

Also listed under: Carrier claims-practice reviews & audits · Reserve studies for carriers · Testimony record

Consulting

Centralizing environmental, asbestos, and toxic tort claims nationally

37field offices consolidated

10,000sof claim files relocated

Carrier claims-practice reviews

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Designed and operationalized a national claims operation to remove CNA’s environmental, asbestos, and toxic tort claims from the 37 field offices and centralize them. This project involved the relocating of tens of thousands of claim files, their proper and adequate reserving, and drafting claim policy & procedure manuals.

Also listed under: Carrier claims-practice reviews & audits

Similar matters, grouped

Open a group to see each matter in it.

6 matters

Estate claim adjudications for Directors of Insurance as Receiver

Claims filed against insurers and risk retention groups in liquidation, investigated, negotiated, and adjudicated, most of them in a supervisory court.

Supervisorycourt adjudications

Hearingclaims taken through to hearing

Show the 6 mattersHide the matters

Supervisory-court adjudication of a medical malpractice claim bookConsultingEstate claims and auditsRead moreShow less

Retained by the South Carolina Director of Insurance as Receiver to investigate, negotiate, and adjudicate in the supervisory court a book of medical malpractice claims. This assignment is heavily composed of claims in New York, New Jersey, and throughout New England and is currently ongoing. The bulk of these claims have policy limits exposures.

Final adjudication of claims against two risk retention groups in liquidationConsultingEstate claims and auditsRead moreShow less

Retained by the South Carolina Director of Insurance to perform the final claim evaluation and adjudication of claims against two Risk Retention Groups in liquidation. This assignment included the investigation, evaluation, and negotiation through hearing of all timely filed proof of claims in the estate.

Final adjudication of a nursing home liability risk retention group’s claimsConsultingEstate claims and auditsRead moreShow less

Retained by the Montana Director of Insurance to perform the final claim evaluation and adjudication of claims against a Nursing Home Liability Risk Retention Group in liquidation. This assignment includes the investigation, evaluation, and negotiation through hearing of all timely filed proof of claims in the estate.

Adjudication of a propane haulers’ claim bookConsultingEstate claims and auditsRead moreShow less

Retained by the South Carolina Director of Insurance as Receiver to investigate, negotiate, and adjudicate in the supervisory court a book of claims for propane haulers. Many of these claims have policy limits exposures.

Adjudication of claims against Philadelphia taxicab ownersConsultingEstate claims and auditsRead moreShow less

Retained by the South Carolina Director of Insurance as Receiver to investigate, negotiate, and adjudicate in the supervisory court a book of claims against Philadelphia taxicab owners.

Adjudication of a commercial trucking risk retention group’s claimsConsultingEstate claims and auditsRead moreShow less

Retained by the South Carolina Director of Insurance as Receiver to investigate, negotiate, and adjudicate in the supervisory court a book of claims against a risk retention group for commercial trucking.

Other matters

Claim audit of an insolvent carrier’s property lossesTestifyingEstate claims and auditsRead moreShow less

Retained by the Receiver of an insolvent carrier to perform a claim audit and examination of property losses. A random selection of the claim population was examined to form opinions about claim handling and payment to determine accuracy of payments and adequacy of claim file documentation.

Also listed under: Receiver’s expert in suits against officers and professionals · Testimony for Receivers and Regulators · Claims Handling Review · Testimony record

Reserve review of a taxicab risk retention groupTestifyingReserve studiesRead moreShow less

Retained as an expert to review the held reserves of a taxicab risk retention group. Upon Mr. Bingham’s final report of audited claim files, the group was ordered into liquidation.

Also listed under: Carrier claims-practice reviews & audits · Reserve studies for carriers

Homeowner claim-file audit in a TPA service-agreement disputeTestifyingDefense of TPAs, agencies, and counselRead moreShow less

Retained by counsel representing a third-party administrator being sued for alleged breaches of a claim service agreement. This assignment included completing an audit of homeowner’s claim files. GIC repeated the TPA’s internal quality control audit and verified their file scoring and conclusory report. This portion of the audit reviewed 112 files. Deliverables included an expert’s report, rebuttal report, and accompanying claim file score sheets. Case was dismissed after opposing expert was stricken.

Also listed under: Defense of TPAs, Agencies, and Counsel

Reserve study of a medical malpractice risk retention group in liquidationConsultingReserve studiesRead moreShow less

Retained by the South Carolina Director of Insurance to perform a reserve adequacy study of a medical malpractice risk retention group, in liquidation. Held reserves were increased as a result of the recommendations in Glynloen’s final report.

Also listed under: Reserve studies for carriers

Review of a claims department’s staffing, procedures, and settlement practicesTestifyingCarrier claims-practice reviewsRead moreShow less

Completed reviews and expert reports assessing propriety of Subject Company’s claim department’s staffing, claims handling policies & procedures, and overall fairness of Company’s claim settlement practices.

Also listed under: Fair claims practices and standards of care · Carrier claims-practice reviews & audits

Day-to-day representative of a court-appointed supervisorConsultingSupervisionRead moreShow less

Retained by the Oklahoma Insurance Department’s Receivership Office to be the day-to-day representative of the court-appointed supervisor of an insurance company: conducting a reserve audit, analysis of the claim operation, and approval of claim payments, with responsibility for a number of other tasks including compliance, reinsurance recoveries, and financial statements, reporting to the supervisor the results of the examination of the company’s operations.

Also listed under: Defense of TPAs, Agencies, and Counsel · Carrier claims-practice reviews & audits · Regulatory Consulting · Receivership & Insolvency Issues

Environmental claim book: reserves, coverage triggers, and allocationTestifyingCarrier claims-practice reviewsRead moreShow less

Retained by a Property and Casualty carrier to review a book of environmental claims and determine reserve adequacy, coverage triggers, and allocation, propriety of investigations and file documentation as well as apportionment of defense and remediation costs. The final report included expert opinions on claim handling and file documentation.

Also listed under: Carrier claims-practice reviews & audits

Claims and reserve auditing.

Why claims and reserves are audited.

Audits, studies, and adjudications.

Reserve adequacy studies

Claim audits and file scoring

Estate claim adjudication and audits

Matters handled.

Three-month trial over a failed insurer’s directors and outside auditor

Errors-and-omissions suit against a failed risk retention group’s directors, auditors, and actuaries

TPA suit over a workers compensation deductible recovery: random 52-file audit

Two-year run-off plan for all claims activity

Reserve studies

Centralizing environmental, asbestos, and toxic tort claims nationally

Similar matters, grouped

Estate claim adjudications for Directors of Insurance as Receiver

Other matters

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