Claims Adjusters, Examiners, and Investigators - What They Do

Individuals and businesses purchase insurance policies to protect against monetary losses. In the event of a loss, policyholders submit claims, or requests for payment, seeking compensation for their loss. Adjusters, appraisers, examiners, and investigators deal with those claims. They work primarily for property and casualty insurance companies, for whom they handle a wide variety of claims alleging property damage, liability, or bodily injury. Their main role is to investigate claims, negotiate settlements, and authorize payments to claimants, who are the policyholders who make a claim. They must be mindful not to violate their rights under Federal and State privacy laws. They must determine whether the customer's insurance policy covers the loss and how much of the loss should be paid. Although many adjusters, appraisers, examiners, and investigators have overlapping functions and may even perform the same tasks, the insurance industry generally assigns specific roles to each of these claims workers.

Adjusters plan and schedule the work required to process a claim. They might, for example, handle the claim filed after an automobile accident or after a storm damages a customer's home. Adjusters investigate claims by interviewing the claimant and witnesses, consulting police and hospital records, and inspecting property damage to determine how much the company should pay for the loss. Adjusters may consult with other professionals, such as accountants, architects, construction workers, engineers, lawyers, and physicians, who can offer a more expert evaluation of a claim. The information gathered—including photographs and statements, either written, or recorded audio or video—is set down in a report that is then used to evaluate the claim. When the policyholder's claim is approved, the claims adjuster negotiates with the claimant and settles the claim. When claims are contested, adjusters will work with attorneys and expert witnesses to defend the insurer's position.

Some large insurance companies centralize claims adjustment in a claims center, where the payout amount is estimated and a check is issued immediately. However, cases handled by independent adjusters, or those involving business losses or homeowner claims, such as hurricane or fire damage, all require a senior adjuster to physically inspect the damage and determine proper compensation.

When it comes to business or residential loss caused by, for example, vandalism or flooding, claimants can opt not to rely on the insurance company's adjuster and may instead choose to hire a public adjuster. Public adjusters are self employed and work in the best interest of the client, rather than the insurance company. In doing so, the adjuster prepares and presents claims to insurance companies, looking to negotiate the best possible settlement for the claimant. Insurance carriers also use the service of independent adjusters on a freelance basis, often in lieu of hiring them as regular employees. In this case the independent adjusters work in the interest of the insurance company.

Claims examiners within property and casualty insurance firms may have duties similar to those of an adjuster, but often their primary job is to review claims after they are submitted in order to ensure that proper guidelines have been followed. They may assist adjusters with complicated claims or when, for instance, a natural disaster suddenly greatly increases the volume of claims.

Most claims examiners work for life or health insurance companies. In health insurance companies, examiners review health-related claims to see whether costs are reasonable given the diagnosis. They use guides that have information on the average period of disability, expected treatments, and average hospital stays for various ailments. Examiners check claim applications for completeness and accuracy, interview medical specialists, and consult policy files to verify the information reported in a claim. They then authorize appropriate payment, deny the claim, or refer the claim to an investigator for a more thorough review. Claims examiners usually specialize in group or individual insurance plans and in hospital, dental, or prescription drug claims.

In life insurance, claims examiners review the causes of death, particularly in the case of an accident, since most life insurance policies pay additional benefits if a death is accidental. Claims examiners also may review new applications for life insurance to make sure that the applicants have no serious illnesses that would make them a high risk to insure.

Another occupation that plays an important role in the accurate settlement of claims is that of the appraiser, whose role is to estimate the cost or value of an insured item. The majority of appraisers employed by insurance companies and independent adjusting firms are auto damage appraisers. These appraisers inspect damaged vehicles after an accident and estimate the cost of repairs. This information is then relayed to the adjuster, who incorporates the appraisal into the settlement.

Many claims adjusters and auto damage appraisers are equipped with laptop computers from which they can download the necessary forms and files from insurance company databases. Specialized software then generates estimates on standard forms. Adjusters also utilize digital cameras, which allow photographs of the damage to be sent to the company, allowing for faster and more efficient processing of claims.

When adjusters or examiners suspect fraud, they refer the claim to an investigator. Insurance investigators handle claims in which the company suspects fraudulent or criminal activity, such as arson, falsified workers' disability claims, staged accidents, or unnecessary medical treatments. The severity of insurance fraud cases can vary greatly, from claimants simply overstating damage to a vehicle to complicated fraud rings supported by dishonest doctors, lawyers, and even insurance personnel.

Investigators usually start with a database search to obtain background information on claimants and witnesses. Investigators can access personal information and identify Social Security numbers, aliases, driver's license numbers, addresses, phone numbers, criminal records, and past claims histories to establish whether a claimant has ever attempted insurance fraud. Then, investigators may visit claimants and witnesses to obtain an oral statement, take photographs, and inspect facilities, such as doctors' offices, to determine, for example, whether the doctors have a proper license. Investigators often consult with legal counsel and can be expert witnesses in court cases.

Often, investigators also perform surveillance work. For example, in a case involving fraudulent workers' compensation claims, an investigator may covertly observe the claimant for several days or even weeks. If the investigator observes the subject performing an activity that is ruled out by injuries stated in a workers' compensation claim, the investigator will take photos to document the activity and report it to the insurance company.

Work Environment

Working environments of claims adjusters, appraisers, examiners, and investigators vary greatly. Many claims adjusters and auto damage appraisers often work outside the office, inspecting damaged buildings and automobiles. Adjusters who inspect damaged buildings must be wary of potential hazards, such as collapsed roofs and floors, as well as weakened structures.

Some adjusters report to the office every morning to get their assignments, while others simply call in from home and spend their days traveling to claim sites. Occasionally, experienced adjusters must be away from home for days—for example, when they travel to the scene of a disaster such as a tornado, hurricane, or flood—to work with local adjusters and government officials.

Most claims examiners employed by life and health insurance companies work a standard 5-day, 40-hour week in a typical office environment. In contrast, adjusters often must arrange their work schedules to accommodate evening and weekend appointments with clients. This sometimes results in adjusters working irregular schedules, especially when they have a lot of claims to scrutinize. Adjusters are often called to work in the event of emergencies and may have to work 50 or 60 hours a week until all claims are resolved.

Appraisers spend much of their time offsite at automotive body shops estimating vehicle damage costs. The remaining time may be spent working in the office. Many independent appraisers work from home, as continually improving valuation software has made estimating damage easier and more routine. Auto damage appraisers typically work regular hours, and rarely work on the weekends. Self employed appraisers also have the flexibility to make their own hours, as many appraisals are done by appointment.

Some days, investigators will spend all day in the office, searching databases, making telephone calls, and writing reports. Other times, they may be away, performing surveillance activities or interviewing witnesses. Some of the work can involve disagreements with claimants, so the job can be stressful and potentially confrontational. Insurance investigators often work irregular hours because of the need to conduct surveillance and contact people who are not available during normal working hours. Early morning, evening, and weekend work is common.

Education & Training Required

There are no formal education requirements for any of these occupations, and a high school degree is typically the minimal requirement needed to obtain employment. However, most employers prefer to hire college graduates or people who have some insurance-related work experience or vocational training.

While a variety of degrees can be an asset, no specific college major is recommended. For example, a claims adjuster who has a business or an accounting background might be suited to specialize in claims of financial loss due to strikes, breakdowns of equipment, or damage to merchandise. College training in architecture or engineering is helpful in adjusting industrial claims, such as those involving damage from fires or other accidents. A legal background can be beneficial to someone handling workers' compensation and product liability cases. A medical background is useful for those examiners working on medical and life insurance claims.

While auto damage appraisers are not required to have a college education, most companies prefer to hire persons with formal training, previous experience, or those with knowledge and technical skills who can identify and estimate the cost of repair. Many vocational colleges offer 2-year programs in auto body repair and teach students how to estimate the costs to repair damaged vehicles.

For investigator jobs, most insurance companies prefer to hire people trained as law enforcement officers, private investigators, claims adjusters, or examiners because these workers have good interviewing and interrogation skills.

Beginning claims adjusters, appraisers, examiners, and investigators work on small claims under the supervision of an experienced worker. As they learn more about claims investigation and settlement, they are assigned larger, more complex claims. Trainees take on more responsibility as they demonstrate competence in handling assignments and progress in their coursework. Auto damage appraisers typically receive on-the-job training, which may last several months. This training usually involves of working under close supervision while estimating damage costs until the employer decides the trainee is ready to perform estimates on their own.

Continuing education is very important for claims adjusters, appraisers, examiners, and investigators because Federal and State laws and court decisions affect how claims are handled and the scope of insurance policies. Also, examiners working on life and health claims must be familiar with new medical procedures and prescription drugs. Examiners working on auto claims must be familiar with new car models and repair techniques.

Many companies offer training sessions to inform their employees of industry changes, and a number of schools and associations give courses and seminars on various topics having to do with claims. Online courses are also making distance learning possible.

Certifications Needed (Licensure)

Licensing requirements for claims adjusters, appraisers, examiners, and investigators vary by State. Some States have few requirements, while others require either the completion of pre-licensing education, a satisfactory score on a licensing exam, or both. Earning a voluntary professional designation can sometimes substitute for completing an exam. In some States, claims adjusters employed by insurance companies can work under the company license and need not become licensed themselves. Public adjusters may need to meet separate or additional requirements. For example, some States require public adjusters to file a surety bond—a unique contract between at least three parties.

Some States that require licensing also require a certain number of continuing education credits per year in order to renew the license. Workers can fulfill their continuing education requirements by attending classes or workshops, by writing articles for claims publications, or by giving lectures and presentations.

Other Skills Required (Other qualifications)

Claims adjusters, appraisers, and examiners often work closely with claimants, witnesses, and other insurance professionals, so they must be able to communicate effectively with others. Knowledge of computer applications also is very helpful. In addition, a valid driver's license and a good driving record are required for workers who must travel on the job. Some companies require applicants to pass a series of written tests designed to measure their communication, analytical, and general mathematical skills.

When hiring investigators, employers look for individuals who have ingenuity and who are persistent and assertive. Investigators should not be afraid of confrontation, should communicate well, and should be able to think on their feet. Good interviewing and interrogation skills also are important and usually are acquired in earlier careers in law enforcement.

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