The Federal Bureau of Investigation estimates that illegitimate insurance claims cost about $40 billion every year. Indeed, insurance fraud is not a victimless crime.

Fraudulent claims raise the price of insurance for everyone. Therefore, it’s in an insurance company’s best interest to verify that every claim is legitimate and accurate. Insurance investigators are most useful in claims involving car accidents and workplace injury. In addition, investigators can investigate property damage. These are all common insurance claims that require an investigation.

Why Do Insurance Companies Hire Insurance Investigators?

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 companies use insurance investigators to combat the prevalence of false or inflated claims. 

Insurance investigators play a crucial role in identifying and preventing fraud. They also ensure that only legitimate claims are approved. For instance, consider a case where a policyholder files a personal injury claim after a car accident. An insurance investigator may review surveillance footage, interview witnesses, and analyze medical records to verify the details of the incident.

In one scenario, the investigator discovers inconsistencies between the claimant’s statements and evidence. By uncovering such discrepancies, the investigator helps the insurance company avoid a costly payout on a fraudulent claim.

Types of Insurance Claims Investigated: Key Areas of Focus

1. Investigating Workers’ Compensation Insurance Claims

Fraudulent workers’ compensation claims can be hazardous to the financial wellbeing of your business. To determine the legitimacy of a claim, an insurance investigator 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?

2. Personal Injury and Insurance Claim Fraud Detection

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 staged the incident to look like it occurred at the business.

3. Property Damage and Theft Insurance Claims

Insurance companies will also hire insurance investigators to investigate property damage and theft claims.

Depending on the property and the claim, an investigator might call in an expert. 

The information gained through this process will help the examiner either confirm or deny that the claim is legitimate.

4. Healthcare/Medical Fraud Claims

Medical fraud claims are investigated by private insurers and public ones, such as Medicare and Medicaid. Both the practitioner and the patient can participate in  sometimes together, to line their own pockets.

Reports that show nearly 10 cents of every dollar spent on healthcare goes toward payouts on fraudulent claims. These insurance scams hurt the bottom line of insurance companies. However, they also hurt other customers. Why? Fraud increases the cost of insurance plans to cover the their losses.

Would you like to learn more about how YapiUSA can help your company investigate insurance claims? Feel free to contact us at (877) 669-6911.