Job Descriptions, Definitions Roles, Responsibility: Claims Adjusters, Appraisers, Examiners and Investigators

Individuals and businesses purchase insurance policies to protect against monetary losses. In the event of a loss, policyholders submit claims, or requests for payment, as compensation for their loss. Adjusters, examiners, and investigators work primarily for property and casualty insurance companies, for whom they handle a wide variety of claims for property damage, liability, and bodily injury. Their main role is to investigate the claims, negotiate settlements, and authorize payments to claimants, but they must always be mindful not to violate the claimant’s 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 to the claimant. Although many adjusters, appraisers, examiners, and investigators have overlapping functions and may even perform the same job, the insurance industry generally assigns specific roles to each of these claims workers.

Adjusters plan and schedule the work required to process a claim that would follow, for example, an automobile accident or damage to one’s home caused by a storm. They investigate claims by interviewing the claimant and witnesses, consulting police and hospital records, and inspecting property damage to determine the extent of the company’s liability. Adjusters may also 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 written or taped statements, is set down in a report that is then used to evaluate a claim. When the policyholder’s claim is legitimate, 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.

Many companies centralize the claims-adjusting operation in a claims center, where the cost of repair is determined and a check is issued immediately. More complex cases, usually involving bodily injury, are referred to senior adjusters. Some adjusters work with multiple types of insurance; however, most specialize in homeowner claims, business losses, automotive damage, or workers’ compensation.

Claimants can opt not to rely on the services of their insurance company’s adjuster and may instead choose to hire a public adjuster. Public adjusters assist clients in preparing and presenting claims to insurance companies and try to negotiate a fair settlement. They perform the same services as adjusters who work directly for companies; however, they work in the best interests of the client, rather than 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 the claims submitted to ensure that proper guidelines have been followed. They may assist adjusters with complex and complicated claims or when a 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 based on the diagnosis. The examiners are provided with guides that supply information on the average period of disability, the expected treatments, and the average hospital stay, for patients with the various ailments for which a claim may be submitted. Examiners check claim applications for completeness and accuracy, interview medical specialists, and consult policy files to verify the information reported in a claim. Examiners will then either authorize the appropriate payment 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, because 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 applicants have no serious illnesses that would make them a high risk to insure and thus disqualify them from obtaining insurance.

Another occupation that plays an important role in the accurate settlement of claims is that of the appraiser, whose role is to assess 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. Auto damage appraisers are valued by insurance companies because they can provide an unbiased judgment of repair costs. Otherwise, the companies would have to rely on auto mechanics’ estimates, which might be unreasonably high.

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. Many adjusters and appraisers use digital cameras, which allow photographs of the damage to be sent to the company via the Internet. Many also input information about the damage directly into their computers, where software programs produce estimates of damage on standard forms. These new technologies allow for faster and more efficient processing of claims.

When adjusters or examiners suspect fraud, they refer the claim to an investigator. Insurance investigators in an insurance company’s Special Investigative Unit handle claims in which a company suspects fraudulent or criminal activity, such as arson cases, false workers’ disability claims, staged accidents, or unnecessary medical treatments. The severity of insurance fraud cases can vary greatly, from claimants simply overstating the damage to a vehicle to complicated fraud rings responsible for many claimants 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 certain 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 a recorded statement, take photographs, and inspect facilities, such as a doctor’s office, to determine whether they 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 would take video or still photographs to document the activity and report it to the insurance company.