The Claim That Doesn't Feel Right

Editorial Series July 2026 Vol. 4 Issue. 5

Welcome to this month’s editorial series, "The Claim That Doesn’t Feel Right." Every experienced adjuster knows the sensation. The story holds together on paper, the documents are all present, and yet something about the claim refuses to sit still in the back of your mind. That feeling is not magic, and it is not paranoia. It is pattern recognition built from hundreds of files, and learning to use it responsibly is one of the most valuable skills in claims work.

This series explores fraud awareness from the adjuster’s side of the desk. We will look at the behavioral cues that deserve attention and the ones that get more credit than they should, the documentation red flags that surface when a file is read carefully, and the ethical and legal boundaries that keep an adjuster’s curiosity from becoming a liability. We will also walk through the referral process itself, including when to escalate to the Special Investigation Unit and how to build a referral that investigators can actually use.

Running through every article is a single conviction: the overwhelming majority of claimants are honest people having a hard week, and they deserve the benefit of the doubt. Fraud awareness done well protects them too, because every dollar paid on a dishonest claim is a dollar drawn from the same pool that serves legitimate policyholders. These articles offer practical guidance for staying alert without becoming cynical, and for investigating suspicion without derailing the claims that deserve a smooth path to resolution.

When Something Feels Off

Instinct is real, but it is not evidence. Experienced adjusters learn to notice the small behavioral signals that suggest a claim may be more than it appears. Understanding where those instincts come from, which cues actually matter, and which ones mislead is the first step toward using suspicion responsibly.

July 23 Claims Pages Staff

The File Tells a Story

Fraud rarely announces itself in an interview. It hides in receipts, timelines, photographs, and estimates that do not quite line up. Learning to read a file the way an investigator reads one helps adjusters catch the patterns that matter while verifying facts instead of jumping to conclusions.

July 23 Claims Pages Staff

How Far Is Too Far

Curiosity is a professional asset right up until it becomes a liability. Adjusters have genuine authority to ask questions and verify facts, but that authority has limits set by statute, regulation, and basic fairness. Knowing exactly where those lines sit protects the file, the carrier, and the claimant.

July 23 Claims Pages Staff

Making the Referral to SIU

A referral to the Special Investigation Unit is a serious step, and both premature and delayed referrals carry real costs. Knowing when the threshold has been met, what a well-built referral package contains, and how the adjuster's role changes after the handoff makes the difference between a useful escalation and a wasted one.

July 23 Claims Pages Staff

Protecting the Honest Claimant

The overwhelming majority of claims are legitimate, and the people filing them are often having one of the worst weeks of their lives. Staying alert to fraud without punishing honest policyholders is a discipline, and it happens to be the strongest bad faith protection a carrier has.

July 23 Claims Pages Staff