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What Does a Claims Examiner Do?

In 2002, a judge appointed a claims examiner to investigate claims of fraud at Enron Corporation, a multimillion dollar company that was involved in money laundering.
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A claims examiner is a person who processes the applications of individuals seeking monetary compensation from insurance companies. In essence, a claims examiner's job is to either deny or reward a claim. An examiner must understand the red flags associated with fraudulent claims and have detailed analysis skills to help them determine if a claim should be rewarded.

Claims examiners are used to identify bankruptcy fraud, healthcare fraud, tax fraud, insurance fraud, consumer fraud, and even money laundering. Numerous companies need examiners to identify fraudulent activity because this helps companies and customers save money.

Investigating a claim is akin to solving a mystery. The claims examiner has the responsibility of finding out whether or not a claim is placed legitimately and must also determine if the person that has placed the claim is furnishing the correct information. The examiner is able to identify individuals who really need help from those who want to misuse the system. Reviewing documentation and private investigation are two of the main jobs of a claims examiner. A claims examiner may also need to place an individual or corporation under surveillance to gain a visual aspect of the situation.

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Many companies are in need of qualified people to become claims examiners, especially in the areas of insurance and workers compensation. Many examiners are responsible for keeping cost down because they have a keen awareness of the company's policies and can determine if a claim should be rewarded. In some cases, a claims examiner must acquire certification to ensure they can responsibly review claims and understand when fraudulent activity is taking place.

When working for a company, the examiner must have detailed knowledge about their field. For example, a claims examiners who works for a medical insurance company must understand different medical conditions and illnesses. They must also understand which medical records are critical to the investigation and in what ways a physical condition or ailment can be legitimized.

In some cases a claims examiner is responsible for identifying asset misappropriation in companies. The judicial system uses claims examiners to investigate fraudulent cases related to smaller companies and even large corporations. In 2002, a judge appointed a claims examiner to investigate claims of fraud at Enron Corporation, a multimillion dollar company that was involved in money laundering. Many claims examiners are vital to contributing to fraud prevention policies as well as establishing ethics programs and guidelines that prevent or reduce fraud.

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John57
Post 7

I worked for an insurance company for several years, and part of the time I was a claims examiner. It can be a very interesting job because it is like a mystery, and you have to put all the pieces together to come up with the best solution.

There are specific guidelines that you have to follow to help you make the right decision in each situation, but sometimes you have a unique situation that is not that cut and dry.

Many times you are using comparisons to help you, but if there aren't enough good comparisons to make, you have to rely on your training and instinct to make the best decisions.

honeybees
Post 6

When my son was driving during an ice storm, he lost control of the car and ran into a sign and lamp post along the highway. The back end of the car was completely ruined, but we still had to have an insurance examiner come and inspect the damage.

Before we could do anything else, we needed to determine if the insurance company would replace the car or how much damage was done that they would cover.

Depending on how many claims they have to check out, it can sometimes take a few days before they are able to get to you. Most of them claims examiners know exactly what to look for and how to determine if something is totaled or just needs to have certain parts replaced.

In our situation, the car was completely totaled, so they sent us a check for the retail value of the car.

andee
Post 5

We recently had a major hail storm that damaged many cars and homes. Several of our neighbors had to have their roofs replaced because of the damage of the hail.

When I called my insurance company to request someone come and look at our roof, he said that they would need to send a claims examiner out to inspect the damage. He also said that if a lot of our neighbors had to have their roofs replaced, that was a good indication that we would too.

It was good to have the claims examiner inspect our roof because when we looked at it we couldn't really tell if there had been damage or not. When he got clear up on top of the house and looked at the whole roof, he did determine that there had been enough damage to replace the roof.

sneakers41
Post 4

@Mutsy - I think that unfortunately the rise in crimes like this will also create a lot of opportunities for people to catch these fraudulent claims.

I think that this happens in the banking industry too with the large amount of mortgage fraud cases out there. I was reading that the FBI was saying that mortgage fraud was one of the fastest growing crimes out there, so if you want to work in the banking industry you could become a fraud examiner and work with the banks.

Just about all major banks have openings for people with this background. I love the investigative aspects of a job like this. It is like you are solving a puzzle little by little.

mutsy
Post 3

@Comfyshoes - You are probably right. I know that they usually look for people with a law enforcement background or some experience as a private investigator because usually these people are great at getting the truth out of people.

I think that this type of job would be fascinating and I bet that no two days would be the same. I know that in Florida you have to have an insurance adjuster’s license but there are a lot of jobs available especially in the area of auto insurance fraud.

I read somewhere that South Florida lead the country in insurance fraud with respect to auto claims so this could explain the abundance of jobs in this field.

comfyshoes
Post 2

@Sunny27 - I am wondering if the insurance company just decided to settle the claim and be done with it rather than allow the man to come back with a larger lawsuit. That could be what happened. I don’t know if they just settle cases with very minor damages or do they pursue them aggressively.

I know that it can’t be an easy job because there are probably so many claims that you really have to have a strategy in place to clear them all.

They have to interview people and gather so much information that maybe they just ended the investigation and moved on much bigger cases.

Sunny27
Post 1

I think that working as a claims examiner would be really exciting work because they say that insurance fraud is on the rise. You must get a sense of satisfaction whenever you catch someone that is lying or trying to receive benefits that they shouldn’t get.

A friend of mine was telling me that she had a minor car accident and called the police even though it was her fault. She said that she hit a really old cargo van that was actually falling apart and there was virtually no damage.

She also said that the man was walking around with no problem and did not seem to have any type of issue.

Well she told me that her insurance company paid this man $2,500 for his medical expenses. She couldn’t believe it. She said that there was nothing wrong with this man.

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