The Claims Investigation

Insurance claims need to be investigated. While most insurance claims should be straightforward, claim investigations are often done to ensure that no misrepresentations or faulty claims are made. After a claim has been filed and an adjuster has done his or her recommendations, a claim investigation may be undertaken if fraud is suspected or lawsuits are received. An investigation will be conducted to look into fraudulent or criminal actions related to the insurance claim.

 

Questionable circumstances leading to the accident or theft may involve reckless imprudence, arson, falsified medical expenses, false injury claims, staged accidents or thefts, deliberate vandalism, or unnecessary medical treatments. The policyholder may likewise claim for an amount that is overly stated than the actual cost of the damage or theft. In cases wherein the claim goes beyond the payment for the repair of the damage or the reimbursement of medical expenses and lawsuits are filed, then an extensive investigation is imperative.

An insurance company has investigators to specifically handle such cases. Investigators conduct background investigations of the parties involved, the professionals (doctors and lawyers) issuing the medical certifications, and witnesses presented. Documents and photographs presented are analyzed. Investigators may likewise tap expert witnesses to validate claims. Sometimes, surveillance work is important when claim amounts are high. Because investigations are undertaken for extraordinary circumstances, the claim process becomes more complicated and claim settlements take longer to handle. Investigations need to be precise and extensive to ensure that the insurance company and its policyholders are protected from fraudulent or unnecessary activities.