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.
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.
Cost estimators collect and analyze data to estimate the time, money, resources, and labor required for product manufacturing, construction projects, or services. Some specialize in a particular industry or product type.
Cost estimators typically do the following:
- Consult with industry experts to discuss estimates and resolve issues
- Identify and quantify cost factors, such as production time and raw material, equipment, and labor expenses
- Travel to job sites to gather information on materials needed, labor requirements, and other factors
- Read blueprints and technical documents to prepare estimates
- Collaborate with engineers, architects, owners, and contractors on estimates
- Use sophisticated computer software to calculate estimates
- Evaluate a product’s cost effectiveness or profitability
- Recommend ways to make a product more cost effective or profitable
- Prepare estimates for clients and other business managers
- Develop project plans for the duration of the project
Accurately predicting the cost, size, and duration of future construction and manufacturing projects is vital to the survival of any business. Cost estimators' calculations give managers or investors this information.
When making calculations, estimators analyze many inputs to determine how much time, money, and labor a project needs, or how profitable it will be. These estimates have to take many factors into account, including allowances for wasted material, bad weather, shipping delays, and other factors that can increase costs and lower profitability.
Cost estimators use sophisticated computer software, including database, simulation, and complex mathematical programs. Cost estimators often use a computer database with information on the costs of other similar projects.
General contractors usually hire cost estimators for specific parts of a large construction project, such as estimating the electrical work or the excavation phase. In such cases, the estimator calculates the cost of the construction phase for which the contractor is responsible, rather than calculating the cost of the entire project. The general contractor usually also has a cost estimator who calculates the total project cost by analyzing the bids that the subcontractors' cost estimators prepared.
Some estimators are hired by manufacturers to analyze certain products or processes.
The following are the two primary types of cost estimators:
Construction cost estimators estimate construction work. More than half of all cost estimators work in the construction industry. They may, for example, estimate the total cost of building a bridge or a highway. They may identify direct costs, such as raw materials and labor requirements, and set a timeline for the project. Although many work directly for construction firms, some work for contractors, architects, and engineering firms.
Manufacturing cost estimators calculate the costs of developing, producing, or redesigning a company’s goods and services. For example, a cost estimator working for a home appliance manufacturer may determine whether a new type of dishwasher will be profitable to manufacture.
Some manufacturing cost estimators work in software development. Many high-technology products require a considerable amount of computer programming, and the costs of software development are difficult to calculate.
Two other groups also sometimes do cost estimating in their jobs. Operations research, production control, cost, and price analysts who work for government agencies may do significant amounts of cost estimating in the course of their usual duties. Construction managers also may spend considerable time estimating costs. For more information, see the profiles on operations research analysts and construction managers.