What is an Insurance Claims Investigation?
Insurance firms frequently look into claims to determine whether they are legitimate. The investigation procedure aids the claims adjuster in making an informed choice regarding how to handle a claim.
Investigations of insurance claims are used to combat the incidence of inflated or fake claims. By spotting an illegal claim as soon as possible, you can avoid paying a fraudster potentially high sums of money. An illegitimate claim is unreasonable or erroneous.
Investigations into insurance claims rely on data from records, interviews, and other sources to determine if a claim is valid or invalid.
Types of Claims Investigated
Workers’ Compensation Claims
Fraudulent workers’ compensation claims can be hazardous to the financial wellbeing of your business. To determine the legitimacy of a claim, an examiner will conduct a workers’ compensation claim investigation.
The investigation seeks to determine two things:
- Is the employee as injured as they claim to be?
- Was the injury acquired while the person was working?
For example, an employee who is injured outside of work Tuesday night but comes in the next day and files a claim indicating that the injury happened at work would be filing a fraudulent workers’ comp claim. Ideally, an investigation would uncover that lie.
Personal Injury Claims
Fraudulent personal injury claims can be just as dangerous as fraudulent workers' compensation claims. A firm or an individual may be the target of personal injury claims. When the victim manufactured the incident so that it appeared as though it happened in front of a business' storefront but actually fell on their own frozen steps, the claim is deemed to be false.
Property Damage and Theft Claims
Insurance companies will also look into theft and property damage claims, such as those involving fire, water, or auto accidents (e.g., theft, burglary, hijacking or robbery).
An investigator might consult an expert, depending on the claim and the property. For instance, they might invite someone to visit and assess the burn patterns in order to determine the start and cause of a fire.
The examiner might use the data gathered during this procedure to corroborate or refute the validity of the claim.
Healthcare/Medical Fraud Claims
These claims are evaluated by both commercial and public insurers, including as Medicare and Medicaid. For financial gain, both the practitioner and the patient may jointly engage in making false or exaggerated healthcare claims.