INSURANCE CLAIM INVESTIGATIONS
The Coalition Against Insurance Fraud estimates that illegitimate insurance claims cost about $80 billion annually and that 10 percent of people think insurance fraud is a victimless crime.
Fraudulent claims raise the insurance price for everyone, so it’s in a company’s best interest to verify that every claim is legitimate and accurate. Car accidents, personal injury, workplace injury, and property damage are all common insurance claims that require an investigation.
Insurance companies often conduct claims investigations to evaluate the legitimacy of a claim. The investigation process helps the claims adjuster make an educated decision about how to proceed with a claim.
Insurance claims investigations are used to combat the prevalence of false or inflated claims. An illegitimate claim is unjustifiable or inaccurate, and by identifying it early, you avoid paying potentially significant costs to a fraudster.
Insurance claims investigations rely on evidence, interviews, and records to conclude whether a claim is legitimate or illegitimate.
There are several types of insurance investigations depending on the claim being made.
Workers’ Compensation Claims
Fraudulent workers’ compensation claims can be hazardous to your business's financial well-being. To determine the legitimacy of a claim, an examiner will conduct a workers’ compensation claim investigation.
Personal Injury Claims
Fraudulent personal injury claims can be equally as hazardous as fraudulent workers’ compensation claims. Personal injury claims can be filed against either a business or against another person. The claim becomes fraudulent when the victim actually fell on their own icy steps but staged the incident to look like it occurred in front of a company’s storefront.
Property Damage and Theft Claims
Insurance companies will also investigate property damage (e.g., fire damage, water damage, or car accidents) and theft claims (e.g., theft, burglary, hijacking or robbery).
An investigator might call in an expert depending on the property and the claim. For example, they might ask for someone to come in and evaluate the burn patterns to discover the origin and cause of a fire.
Healthcare/Medical Fraud Claims
Private and public insurers, such as Medicare and Medicaid, investigate these claims. Both the practitioner and the patient can participate in fake or inflated healthcare claims, sometimes together, to line their own pockets.
Investigations include:
Written and Recorded Statements
Accident Scene Investigation with Photos
Auto Liability and Bodily Injury Claims
Workers’ Compensation Investigations
Alive and Well Being Checks with Interviews
Provide Diagrams and Measurements
Property Damage Claims
Stolen Vehicles, Boats, Airplanes, etc.
Locate Witnesses and Conduct Interviews
Life and Health Claims
Staged Motor Vehicle Accident Investigations
Disability Investigations
Slip and Fall Investigations
Surveillance of Individuals Claiming Injury
Activity Checks
Background Investigations
Asset Checks
Document Retrieval