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What is an Insurance Claims Investigator?

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  • Written By: Tricia Ellis-Christensen
  • Edited By: O. Wallace
  • Last Modified Date: 18 November 2016
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Were it not for the fact that insurance fraud occurs, insurance companies wouldn’t need insurance claims investigators. Unfortunately, there are many different types of insurance scams and false claims, and insurance companies may lose lots of money if they merely pay out on claims they think may be dubious. To avoid this loss, many insurance companies have on their staff or contract with at least one insurance claims investigator so they can attempt to only pay legitimate claims.

Usually, the help of the insurance claims investigator is solicited when a company suspects fraud. Suspicion may occur during the first few examinations of a claim, which may be conducted by insurance examiners or insurance adjusters. The investigator will review the case, going over all information provided by the company and claimants. He or she also may investigate the claimants to a certain degree to find out if they have information in their past that might suggest fraudulent behavior in the present. Searches for criminal records might be conducted, the investigator could look for collusion between claimants and witnesses, and he might also re-interview anyone involved in the claim.

In some instances the insurance claims investigator doesn’t just sift through witness/claimant details, but might be out in the field. He might need to perform surveillance or examine the scene of an accident. The job may vary between active and passive searching for evidence for insurance fraud.

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There may be special requirements to become an insurance claims investigator. Some people move from private investigation or law enforcement work into this field. Others can study criminal justice at the college level, most often earning a bachelor’s degree prior to entering this field. Familiarity with state insurance laws is also vital, and any good investigator is going to have to know common means by which people attempt to commit insurance fraud.

Another of the requirements to become an insurance investigator may be state licensing. In some states investigators must be licensed as private investigators. This may vary, and people should look into their state or country laws to determine specific requirements.

In addition to requiring some studying and knowledge, any insurance claims investigator needs to have a finely trained mind: one that can spot deception easily, see patterns in gathered information, and look for ways to prove suspicions. People who may enjoy this field like logic, reasoning and puzzles, and aren’t afraid to do active detection work when required. A high degree of organization may also be needed, since sifting through all paperwork and gathered evidence is made more difficult when organization is haphazard.

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Sporkasia
Post 4

@Laotionne - I was once a fan of those TV PI shows that you are talking about, but I know someone who works as a private investigator in the real world and he assures me that his job doesn't look much like what you see investigators on TV doing.

Something tells me that a claims adjuster's job would be more like the job of a real life private investigator and not as exciting as what we see private investigators doing on TV. It always looks more interesting on TV and in the movies.

Laotionne
Post 3

Being an insurance claims investigator sounds like it would be a cool job to have. I like a job where I get a variety of assignments and working in the field instead of behind a desk all day would be a welcomed change.

Most people who watch TV private eye shows secretly want to be tin the roles of he actors they watch on the screen. As a claims investigator you could be like those TV private investigators.

Animandel
Post 2

I pay my insurance premiums on time and I don't complain about increases and other changes in my policies. I am a good customer for the insurance company. When I make a claim I want to be treated like a good customer and an honest person because that's who I am. When we made a claim on our homeowner's insurance policy you would have thought we had intentional cut down a tree and had it fall on our house.

I don't like having to answer a thousand questions and talk to various insurance company workers, such as claim adjusters and investigators, before I receive what I am entitled to.

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