Insurance Claim Process

What is Involved in the Insurance Claim Process?

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
• Negotiate settlements
• Authorize payments

Claims adjusters, appraisers, examiners, and investigators have varying duties, depending on 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 in order 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.

What Steps Are Part of the Insurance Claim Process?

1. Adjusters inspect property damage or personal injury claims to determine how much the insurance company should pay for the loss. They might inspect a home, a business, or an automobile.

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

3. Adjusters gather information—including photographs and statements, either written or recorded on audio or video—and put together a report for claims examiners to evaluate. When the examiner approves the claim, the adjuster negotiates with the policyholder and settles the claim.

4. 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.

Some claims adjusters work as 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. They are paid a percentage of the settled claim.

Adjusters are hired to handle various aspects of insurance claims; the three main types are staff adjuster, independent adjuster, and public adjuster. Staff adjusters work for insurance companies, while public adjusters are hired by claimants. Independent adjusters do not work for a particular insurance company but are hired on an as-needed basis by them to investigate claims.