How Do Insurance Investigators Investigate?

If you have ever been in even the smallest fender-bender after which an insurance claim was made, you know that insurance companies take a serious look at all the evidence before they offer a settlement. Unfortunately, this is often frustrating for the consumer because insurance premiums are high, and individuals expect to be compensated to the fullest when they need to use the policy.

What many fail to understand, however, is that part of the reason premiums are so costly is the sheer number of fraudulent insurance claims that are made every year. If you think insurance fraud is a victimless crime, you are wrong—it affects everyone by driving up the cost of insurance. Therefore, whether it is a property damage claim, a car accident, or personal injury, insurance companies need to investigate these claims to ensure their legitimacy.

Why Do They Investigate?

Insurance companies need to investigate every claim made on a policy for the claims adjuster to have accurate details about the situation before denying the claim or offering a settlement. Unfortunately, many individuals will exaggerate a claim or file an utterly false claim in an attempt to collect insurance money, so the company must conduct research before paying out.

The type of insurance investigation that occurs depends upon the claim that is made. This may require gathering records, evidence, and conducting interviews as a means of determining whether a claim is genuine.

What Types of Claims Do Insurance Companies Investigate?

  • Medical fraud and health care claims. Public insurers such as Medicaid and Medicare, and private companies may investigate these types of claims. Unfortunately, at times, practitioners and patients file false claims, or the two may be working together to perpetrate a fraud.
  • Theft and property damage claims. These claims may include various unfortunate events, such as robbery, hijacking, burglary, auto accidents, and water or fire damage. Insurance companies often investigate these claims and will sometimes rely on experts, depending on the specifics of the case. For example, expert investigators can determine whether a claim is legitimate in many cases by examining evidence such as burn patterns in a house fire. Such evidence may be impossible for most individuals to correctly evaluate, but trained professionals can use it to determine the fire’s origin and cause.
  • Personal injury cases. There are several ways to file a false personal injury claim against another individual or a business. One typical example is an individual who falls on the ice and becomes injured at home but later creates a staged scene in front of a business to make it appear that they were injured there.
  • Workers’ compensation claims. These types of claims not only affect the insurer but the company that the individual works for. To protect the company’s financial well-being, a claims examiner may investigate the claim to determine whether the individual is injured and whether the injury happened while working. For instance, a person who gets hurt at home but stages a scene in which they claim to be injured at work may be exposed by a workers’ comp investigator.

How Does the Process Work?

Just as a detective investigates any other crime, a claims investigator uses a process that involves steps such as analyzing claimants’ social media, conducting surveillance, photographing and inspecting the accident site or damaged property, finding and interviewing witnesses, taking statements, and collecting and analyzing documents.

  • How does social media help? Contextual information such as clues found on social media helps investigators learn details about the claim in question and the individual in general. For instance, an individual who posts about being an extreme sports enthusiast may be likely to have gotten injured during such activities. Likewise, posts by someone who complains about their job or having financial difficulties may indicate a propensity toward committing insurance fraud.

    An investigator will often dig deeper to see if such individuals have ever made previous claims and if the claim was similar and whether it was found to be fraudulent.

  • Surveillance of the individual and the area is helpful. Videos and photographs can be used to piece a story together. Whether a claim originated in a vehicle on the road, at home, or in the workplace, photos of an injury and the location where it supposedly occurred can help investigators accept or rule out whether a claim is legitimate.

    Surveying the person who made the claim can also be helpful, as seeing someone who claims to have a severe injury dancing in a nightclub or lifting weights in a gym can nullify their claim.

  • Interviewing and taking witness statements is a prime way to gather information. When an investigator has access to statements from witnesses and the victim, it can be helpful in various ways. For this reason, they will often ask for a written or recorded statement from anyone involved in the incident. In addition to providing an initial account of the situation, such reports can also disprove false claims during interviews. When an investigator interviews a claimant, they can compare the original report to the answers they get to see if the story has stayed the same. Often, fraudsters have a hard time keeping their stories straight.
  • Reviewing documents is a crucial component of any investigation. Insurance investigators will always want all the official records from the damage or injury in the claim. In the case of personal injury claims, doctor and hospital records may be requested, in addition to prescription records and medical release forms. If the injury occurred on the job, OSHA forms would also be requested. This information is all used to determine the severity and legitimacy of the injury.

If the investigator is looking into a claim for property damage in a car accident, they will use the accident and police reports in addition to any other evidence they gather. For example, in theft claims, they will typically ask the individual to provide photographs of or receipts for the items they say were stolen. This helps to establish that they owned the items.

Trust the Investigators With Experience

If you are an employer who suspects an employee has committed workers’ compensation fraud or an insurance company that needs a skilled investigation team to verify or disprove claims, the professionals at Amatrix Investigations, Inc., have a proven track record in the industry. Visit our website to see how we can help you expose the truth.

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