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Claims Adjusters, Appraisers, Examiners, and Investigators

Claims adjusters, appraisers, examiners, and investigators evaluate insurance claims. They decide whether an insurance company must pay a claim, and if so, how much. Show Details

Duties

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
  • Keep claims files, such as records of settled claims and an inventory of claims requiring detailed analysis
  • Negotiate settlements
  • Authorize payments

What insurance adjusters, examiners, and investigators do varies by 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. 

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.

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.

Adjusters inspect property damage to determine how much the insurance company should pay for the loss. The property they inspect could be a home, a business, or an automobile.

They interview the claimant and witnesses, inspect the property, and do additional research, such as look at police reports. Adjusters 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.

They gather information—including photographs and statements, either written or recorded audio or video—and put it in a report that claims examiners use to evaluate the claim. When the examiner approves policyholder's claim, the claims adjuster negotiates with the claimant 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.

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 that proper guidelines have been followed by claimants and adjusters. 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 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 claimants overstating vehicle damage 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 activities that would be ruled out by injuries stated in the claim.

Insurance Underwriters

Insurance underwriters decide whether to provide insurance and under what terms. They evaluate insurance applications and determine coverage amounts and premiums. Show Details

Duties

Insurance underwriters typically do the following:

  • Analyze information in insurance applications
  • Determine the risk of insuring a client
  • Screen applicants on the basis of set criteria
  • Evaluate recommendations from underwriting software
  • Decide whether to offer insurance
  • Determine appropriate premiums and amounts of coverage
  • Write policies to cover potential loss

Underwriters are the main link between an insurance company and an insurance agent. Insurance underwriters use computer software programs to determine whether to approve an applicant. They take specific information about a client and enter it into a program. The program then provides recommendations on coverage and premiums. Underwriters evaluate these recommendations and, using predetermined criteria, decide whether to approve or reject the application. If a decision is difficult, they may consult additional sources, such as medical documents and credit scores.

Insurance underwriters must achieve a balance between risky and cautious decisions. If underwriters allow too much risk, the insurance company will pay out too many claims. But if they don't approve enough applications, the company will not make enough money from premiums.

Most insurance underwriters specialize in one of four broad fields: life, health, mortgage, and property and casualty. Although job duties are similar, the criteria used by underwriters vary. For example, for someone seeking life insurance, underwriters consider age and financial history. For someone applying for car insurance (a form of property and casualty insurance), underwriters consider the person's driving record.

Within the broad field of property and casualty, underwriters may specialize even further into commercial (business insurance) or personal insurance. They may also specialize by the type of policy, such as insuring automobiles, boats (marine insurance), or homes (homeowners’ insurance).

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