Responsible for handling claims that have triggered red flags or that companies suspect are fraudulent. Investigates claims to uncover criminal activity, false claims, staged accidents, or unnecessary medical treatments.
- Investigate suspicious insurance claims, including those that are suspected to have stemmed from fraud, criminal activity, arson, falsified documents, or unnecessary medical procedures.
- Consult police and hospital records.
- Consult with accountants, architects, construction workers, engineers, lawyers, and physicians to get expert evaluation.
- Examine photographs and statements.
- Listen to or watch audio or video surveillance.
- Record data and statements in report.
- Obtain background information on claimants and witnesses using a universal database.
- Access personal information and identify Social Security numbers, aliases, driver's license numbers, addresses, phone numbers, criminal records, and past claims histories.
- Search for previous cases of fraud.
- Visit claimants to obtain oral statements.
- Inspect facilities and determine if doctors hold proper licenses and certifications.
- Perform surveillance work to determine if a claimant is performing rigorous activity that would rule out injuries in workers' compensation claim.
- Take photos and document suspicious activity.
- Report all activity to insurance company for final determination.
- Testify in court cases when claimant is accused of fraud.