Claims Adjusters, Appraisers, Examiners, and Investigators
Nature of the Work
Claims adjusters, appraisers, examiners, and investigators evaluate insurance claims. They decide whether an insurance company must pay a claim and, if so, how much.
Claims adjusters, appraisers, examiners, and investigators typically do the following:
Investigate, evaluate, and settle insurance claims
Determine whether the insurance policy covers the loss claimed
Decide the appropriate amount the insurance company should pay
Ensure that claims are not fraudulent
Contact claimants' doctors or employers to get additional information on questionable claims
Confer with legal counsel on claims when needed
Claims adjusters, appraisers, examiners, and investigators have varying duties, depending on the type of insurance company they work for. They must know a lot about what their company insures. For example, workers in property and casualty insurance must know housing and construction costs to properly evaluate damage from floods or fires. Workers in health insurance must be able to determine which types of treatments are medically necessary and which are questionable.
Adjusters inspect property damage to determine how much the insurance company should pay for the loss. They might inspect a home, a business, or an automobile.
Adjusters interview the claimant and witnesses, inspect the property, and do additional research, such as look at police reports. They may consult with other workers, such as accountants, architects, construction workers, engineers, lawyers, and physicians, who can offer a more expert evaluation of a claim.
Adjusters gather information—including photographs and statements, either written or recorded on audio or video—and put together a report for claims examiners to evaluate. When the examiner approves the claim, the adjuster negotiates with the policyholder and settles the claim.
If the claimant contests the outcome of the claim or the settlement, adjusters work with attorneys and expert witnesses to defend the insurer's position.
Some claims adjusters work as self-employed public adjusters. Often, they are hired by claimants who prefer not to rely on the insurance company's adjuster. The goal of adjusters working for insurance companies is to save as much money for the company as possible. The goal of a public adjuster working for a claimant is to get the highest possible amount paid to the claimant. They are paid a percentage of the settled claim.
Sometimes, self-employed adjusters are hired by insurance companies in place of hiring adjusters as regular employees. In this case, the self-employed adjusters work in the interest of the insurance company.
Appraisers estimate the cost or value of an insured item. Most appraisers who work for insurance companies and independent adjusting firms are auto damage appraisers. They inspect damaged vehicles after an accident and estimate the cost of repairs. This information then goes to the adjuster, who puts the estimated cost of repairs into the settlement.
Claims examiners review claims after they are submitted to ensure claimants and adjusters followed proper guidelines. They may assist adjusters with complicated claims or when, for example, a natural disaster occurs and the volume of claims increases.
Most claims examiners work for life or health insurance companies. Examiners who work for health insurance companies review health-related claims to see whether the costs are reasonable, given the diagnosis. After they review the claim, they authorize appropriate payment, deny the claim, or refer the claim to an investigator.
Examiners who work for life insurance companies review the causes of death and pay particular attention to accidents, because most life insurance companies pay additional benefits if a death is accidental. Examiners also may review new applications for life insurance policies, to make sure that the applicants have no serious illnesses that would make them a high risk to insure.
Insurance investigators handle claims in which the company suspects fraudulent or criminal activity such as arson, staged accidents, or unnecessary medical treatments. The severity of insurance fraud cases varies, from overstated claims of damage to vehicles to complicated fraud rings. Investigators often do surveillance work. For example, in the case of a fraudulent workers' compensation claim, an investigator may covertly watch the claimant to see if he or she does anything that would be ruled out by injuries stated in the claim.