Three parties, and only one of them decides
How a claim is decided
An agency that tells you on the telephone that you are covered is guessing with your money. Here is who actually decides, what we can genuinely do about it, and the two places to go when we have run out of usefulness.
We report your claim. We do not decide it. We do not decide your claim, and no agency does. Coverage is decided by the carrier's adjuster against the policy wording, and an agency that tells you on the telephone that you are covered is guessing with your money. What we can do is real but limited: report the loss the same day, send the carrier the policy and endorsement history, put our reading of the wording in writing, escalate above the adjuster, and tell you plainly when we think a denial is wrong. If you need somebody to negotiate the settlement figure itself, that is a public adjuster, licensed separately by the Department of Financial Services, and it is not us.
After a loss there are three parties with opinions about whether you are covered, and only one of them has any authority. The carrier's adjuster applies the policy wording to the facts, and their decision is the one that produces money.
You can dispute that decision, escalate it, complain about it to the regulator, appoint a licensed public adjuster to negotiate it, or sue on it. This agency can do none of those things for you, and what it can do is narrower and more useful than the industry usually admits.
What we can genuinely do
Report the loss the same day and inside the deadlines. Several New York deadlines are specific: no-fault benefits generally need the written application within thirty days of a motor accident and bills within forty-five days of treatment. Late notice is one of the commonest reasons a valid claim fails, and it is entirely avoidable.
Send the carrier your complete policy and endorsement history, so what was in force on the date of loss is established from the record rather than reconstructed under pressure. Help you assemble what the adjuster will want before they ask for it.
Chase a file that has gone quiet, and escalate past an adjuster who is not moving — to a supervisor, then to the carrier's claims management. And where we think a denial is wrong, say so in writing quoting the wording we think applies. Carriers do reverse decisions when the argument is specific and documented, and persistence is a genuine service rather than a courtesy.
What we will not do, and why that is deliberate
We will not tell you that you are covered. We will tell you what we think the wording says and label it as our reading, because the adjuster decides and we do not.
And we will not negotiate your settlement figure. In New York, negotiating a claim on an insured's behalf is the work of a public adjuster, licensed separately by the Department of Financial Services. Documenting, estimating and quoting the wording without negotiating, and charging nothing for any of it, is not. Taking no fee for claims work is therefore structural as well as generous — it is part of what keeps this agency on the right side of that line.
When you need somebody who is not us
A public adjuster, when a large or contested claim needs the number itself argued professionally. They work for you rather than the insurer, they are licensed by the Department, and their fee is a percentage of the recovery. On a small straightforward claim they are usually not worth it; on a serious fire loss they frequently are. We have no financial interest either way and will say what we think if you ask.
The Department of Financial Services, when you have exhausted the adjuster and the supervisor. A consumer complaint is free, it is handled by the regulator that licenses the carrier, and insurers take it seriously in a way that a further telephone call is not taken seriously. We will tell you when you have reached that point, including when the carrier we placed you with is the one being complained about.
A lawyer, for an injury claim against another party, for a denial you intend to challenge in court, or where the serious injury threshold under New York's no-fault system is in question. That is a legal judgment and not one an agency should be making for you.
Whether to claim at all
Not every loss should be reported as a claim, and the arithmetic is worth doing before you pick up the telephone. A $2,400 loss on a $1,000 deductible nets you $1,400. If it raises your premium for five years and costs you a claims-free credit, it can easily cost more than it pays.
That calculation does not apply to liability, and it does not apply to anything involving injury to another person. Report those immediately regardless of what you think they are worth: late notice on a liability claim is far more expensive than a premium increase, and you are not in a position to value somebody else's injury.
In order
How this works in practice
Ring the same day
Even if you are unsure whether to claim. Reporting a loss and pursuing it are different decisions, and the first preserves the second.
We send the history
Your full policy and endorsement record, so what was in force is established from the file rather than argued about.
The adjuster inspects and decides
They apply the wording to the facts. That decision is the one that produces money, and it is not ours to make.
We escalate if it stalls
Adjuster, supervisor, claims manager — in writing, quoting the wording. Carriers do reverse decisions on specific arguments.
Then the regulator, or a public adjuster
A DFS complaint is free. A public adjuster negotiates for a percentage. We will tell you which one you have reached.
Questions we are actually asked
How a claim is decided — frequently asked
Can my agent tell me if I am covered?
We can tell you what we think the wording says and put it in writing as our reading. We cannot tell you that you are covered — the carrier's adjuster decides that against the policy. Any agency answering that question definitively on the telephone is guessing with your money.
What does a public adjuster do?
Negotiates the settlement of your claim on your behalf, for a fee that is a percentage of the recovery. They are licensed separately by the Department of Financial Services. We do not negotiate claims and do not hold that licence, and we will tell you when your claim has reached the point where one is worth engaging.
How do I complain about my insurance company?
The New York Department of Financial Services takes consumer complaints about insurers it licenses, free of charge, and carriers respond to them seriously. It is the right step once the adjuster and their supervisor have been exhausted. We will tell you when you are there, including when it is a carrier we placed you with.
Will you help with a claim on a policy you did not place?
We will talk you through it and tell you what we would do, at no charge. What we cannot do is act for you with a carrier we have no agency relationship with — reporting and escalation run through the producer of record, which in that case is somebody else.
Read next
Related reading
Bring the declarations page and we will read it with you
Ask us what it would cost
Send or bring the summary pages of what you already have — those two sheets are where most of the useful conversation is. We will tell you what we would place it with and what that would cost, what we are paid for doing it, and whether you should move at all. Quite often the answer is that your current policy is priced fairly and you should keep it, and that is an answer we give in writing like any other.