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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.

Judges, Mediators, and Hearing Officers

Judges, mediators, and hearing officers apply the law to court cases and oversee the legal process in courts. They also resolve administrative disputes and facilitate negotiations between opposing parties. Show Details

Duties

Judges, mediators, and hearing officers typically do the following:

  • Research legal issues
  • Read and evaluate information from documents such as motions, claim applications, or records
  • Preside over hearings and listen to or read arguments by opposing parties
  • Determine if the information presented supports the charge, claim, or dispute
  • Decide if the procedure is being conducted according to the rules and law
  • Analyze, research, and apply laws, regulations, or precedents to reach judgments, conclusions, or agreements
  • Write opinions, decisions, or instructions regarding the case, claim, or dispute

Judges commonly preside over trials or hearings of cases regarding nearly every aspect of society, from individual traffic offenses to issues concerning the rights of large corporations. Judges listen to arguments and determine whether the evidence presented deserves a trial. In criminal cases, judges may decide that people charged with crimes should be held in jail until the trial, or they may set conditions for their release. They also approve search and arrest warrants.

Judges interpret the law to determine how a trial will proceed, which is particularly important when unusual circumstances arise for which standard procedures have not been established. They ensure that hearings and trials are conducted fairly and the legal rights of all involved parties are protected.

In trials in which juries are selected to decide the case, judges instruct jurors on applicable laws and direct them to consider the facts from the evidence. For other trials, judges decide the case. A judge who determines guilt in criminal cases may impose a sentence or penalty on the guilty party. In civil cases, the judge may award relief, such as compensation for damages, to the parties who win the lawsuit.

Some judges, such as appellate court judges, review decisions and records made by lower courts, and make decisions based on lawyers’ written and oral arguments.

Judges use various forms of technology, such as electronic databases and software, to manage cases and prepare for trials. In some cases, a judge also may manage the court’s administrative and clerical staff.

The following are examples of types of judges, mediators, and hearing officers:

Judges, magistrate judges, and magistrates preside over trials or hearings. They typically work in local, state, and federal courts.

In local and state court systems, they have a variety of titles, such as municipal court judge, county court judge, magistrate, and justice of the peace. Traffic violations, misdemeanors, small-claims cases, and pretrial hearings make up the bulk of these judges' work.

In federal and state court systems, general trial court judges have authority over any case in their system. Appellate court judges rule on a small number of cases by reviewing decisions of the lower courts and lawyers’ written and oral arguments.

Hearing officers, also known as administrative law judges or adjudicators, usually work for government agencies. They decide many issues, such as if a person is eligible for workers' compensation benefits, or if employment discrimination occurred.

Arbitrators, mediators, or conciliators help opposing parties settle disputes outside of court. They hold private, confidential hearings, which are less formal than a court trial.  

Arbitrators are usually attorneys or business people with expertise in a particular field. They hear and decide disputes between opposing parties as an impartial third party. When arbitration is required, if one side is not happy with the decision, they can still take the matter to court. Arbitration may also be voluntary, in which the opposing sides agree that whatever the arbitrator decides will be a final, binding decision.

Mediators are neutral parties who help people resolve their disputes. Mediators suggest solutions, but they do not make binding decisions. If the opposing sides cannot reach a settlement with the mediator's help, they are free to pursue other options.

Conciliators are similar to mediators. Their role is to help guide opposing sides to a settlement. The opposing sides must decide in advance if they will be bound by the conciliator's recommendations.

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