Claims adjuster/examiner
Fraud investigator
The job -- Claims adjusters and examiners work for insurance companies.
They decide whether claims are covered by the customer’s policy, confirm
payment, and, when necessary, investigate the circumstances surrounding a
claim. Claims adjusters work for property and liability insurance carriers or
for independent adjusting firms. They interview the claimant and witnesses,
review police and hospital records, and inspect property damage. Claims
examiners work for life and health insurance carriers and investigate
questionable claims or those exceeding a designated amount. Examiners
check claim applications for completeness and accuracy, interview medical
specialists, and consult policy files to verify information on a claim. Some
in this occupation work a typical 40-hour week in an office. However,
adjusters work outside the office, inspecting damaged buildings and
automobiles. Occasionally, experienced adjusters are away from home for days when they travel to the
scene of a disaster—such as a tornado, hurricane, or flood—to work with local adjusters and
government officials. (See Fraud investigator for more information on this field.)
Educational requirements -- Most companies prefer to hire college graduates. No specific college
major is recommended for these occupations. An adjuster who has a business or an accounting
background might specialize in claims of financial loss due to strikes, breakdowns in equipment, or
damage to merchandise. College training in engineering is helpful in adjusting industrial claims, such
as damage from fires and other accidents. A legal background is helpful in handling workers’
compensation and product liability cases. Entry-level workers may be hired without a college degree if
they have specialized experience. For example, people with knowledge of automobile mechanics or
body repair may qualify as material damage adjusters. Knowledge of computer applications is
extremely important for all claim representatives. Beginning adjusters and examiners work on small
claims under the supervision of an experienced worker. Trainees are promoted as they demonstrate
competence in handling assignments and as they progress in required coursework.
The job — Insurance fraud, simply put, is lying to an insurance company to get
money. Many insurance companies have special investigation units that look into
cases where fraud is suspected. Within state government, the Insurance Fraud
Investigation Division is the Department of Insurance’s law enforcement agency.
The state division is empowered to conduct criminal investigations of suspected
fraudulent insurance acts. Investigations of suspicious activity may require
irregular work hours and travel. In addition, there may be substantial contact with
the public.
Educational requirements — In the private sector, applicants are often required
to have a bachelor’s degree and previous experience in insurance and
investigations. Applicants for a state position as a Insurance Fraud Investigator I must have a bachelor’s
degree. However, the following work experience will substitute for the required education on a
year-for-year basis: experience in investigative law enforcement; experience in the insurance industry in
financial analysis, claims processing, or management; experience dealing with substantive insurance
issues with an insurance regulatory agency or a related agency; or experience as an insurance licensee.
Criminal investigators are required to be certified law enforcement officers within one year of hire.
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