An insurance company's reputation and success is dependent upon its ability to quickly and effectively investigate claims, negotiate equitable settlements, and authorize prompt payments to policyholders. Claims representatives perform these duties.
Claims clerks review insurance forms for accuracy and completeness. Frequently, this involves calling or writing the insured party or other people involved to secure missing information. After placing this data in a claim file, the clerk reviews the insurance policy to determine coverage. Routine claims are transmitted for payment; if further investigation is needed, the clerk informs the claims supervisor.
In companies specializing in property and casualty insurance, claims adjusters may perform some or all of the duties of claims clerks. They can determine whether the policy covers the loss and amount claimed. Through investigation of physical evidence, the securing of testimony from relevant parties, including the claimant, witnesses, police, and, if necessary, hospital personnel, and the examination of reports, they promptly negotiate a settlement. Adjusters make sure that the settlement reflects the actual claimant losses, while making certain the insurer is protected from invalid claims.
Adjusters may issue payment checks or submit their findings to claims examiners for payment. If litigation is necessary, adjusters recommend this action to legal counsel, and they may attend court hearings.
Most claims adjusters specialize in one type of insurance. They act exclusively in one field, such as fire, marine, automobile, or product liability. A special classification is the claims agent for petroleum, who handles activities connected with locating, drilling, and producing oil or gas on private property. In states with "no fault" insurance, adjusters are not concerned with responsibility, but they still must determine the amount of payment. To help settle automobile insurance claims, an automobile damage appraiser examines damaged cars and other vehicles, estimates the cost of labor and parts, and determines whether it is more practical to make the repairs on the damaged car or to pay the claimant the precollision market value of the vehicle.
For minor or routine claims, the trend among property and casualty insurers is to employ telephone or inside adjusters. They use the telephone and written correspondence to gather information, including loss estimates, from the claimant. Drive-in claim centers have developed to provide on-the-spot settlement for minor claims. After determining the loss, the adjuster issues a check immediately.
Outside adjusters handle more complex claims. They spend more time in the field investigating the claim and gathering relevant information.
Public adjusters are self-employed professionals who are hired by claimants who prefer not to rely on the insurance company’s adjuster. As advocates of the claimant, public adjusters try to obtain the highest amount for their client (as opposed to adjusters who work for insurance companies, who have a goal of limiting the payout amount). Public adjusters are paid a percentage of the settled claim.
In life and health insurance companies, claims examiners perform all the functions of claims adjusters. Examiners in these companies, and in others where adjusters are employed, review settled claims to make sure the settlements and payments adhere to company procedures and policies. They report on any irregularities. In cases involving litigation, they confer with attorneys. Where large claims are involved, a senior examiner frequently handles the case.
Some people try to defraud insurance companies by applying for compensation for staged accidents, unnecessary medical treatments, or fire damage that is actually caused by arson. When the insurance company suspects fraudulent or criminal activity it assigns an insurance investigator to look into the facts of the claim and often conduct surveillance work on the claimant to see if his or her claims (e.g., workplace injury prompting the loss of an ability to work, etc.) are valid.
- Accountants and Auditors
- Business Managers
- Financial Institution Officers and Managers
- Financial Quantitative Analysts
- Forensic Accountants and Auditors
- Fraud Examiners, Investigators, and Analysts
- Health Care Insurance Navigators
- Insurance Fraud Investigators
- Insurance Policy Processing Workers
- Insurance Underwriters
- Life Insurance Agents and Brokers
- Property and Casualty Insurance Agents and Brokers
- Regulatory Affairs Managers
- Risk Managers