Questa volta abbiamo cercato: How do insurance companies determine the legitimacy of claims? Do they have the authority to investigate like the police?
How do insurance companies determine the legitimacy of claims? Do they have the authority to investigate like the police?
Ed ecco le risposte:
Really depends on what type of insurance
Car insurance – 99% of the time you make a claim from an accident there is a police report. They will also contact you and the other party. If it’s a claim of you maybe hitting your garage or a tree branch falling on your car they will see damage estimates from shops and base it off that.
Home owners- send an adjuster most of the time
Life insurance – death certificate
Disability – doctor must report
Etc
In all insurance claims, you as the insured have the obligation to prove your claim. The insurers do not need “police-like” powers because documentation has to be provided by the insured. No documentation = no loss.
I don’t think they have subpoena powers, if that’s what you’re asking. But as a completely legal layperson, my assumption that if they suspect the insured is lying, that’s criminal fraud and the police then will investigate.
Health insurance – burden of proof is on the submitter, so doctors offices, hospitals, etc. frequently have to submit documentation showing services performed, and medical necessity of the service before receiving payment.
This is actually what I do. I’m an investigator for a major insurance company.
If the legitimacy of a claim is in question, we do investigate it. Insurance investigators aren’t cops, and we don’t have any special police powers. We do have access to certain databases that can let us run background checks, see claims history, run relationship reports, and find pictures of your vehicle or house or whatever.
Most importantly, your policy requires you to cooperate with any investigation. So we might ask for things like phone records, location records, etc. Sometimes we will retrieve crash data from your car, or order forensic analysis. We will also do a very extensive interview with you. Our requests must be relevant and reasonable (ie, I’m not going to ask for your PIN number or a letter from the President, but if I’m investigating a suspicious theft, I might ask for bank records). Failure to provide requested documents, or failure to cooperate could result in your claim being denied.
Ultimately, we basically just want to figure out if you are being honest or lying. It’s on us to prove that you are lying, but we have a surprising number of ways to do that. Misrepresentation is grounds for the claim to be denied (it’s also fraud, and we do report to the relevant law enforcement agency). Ultimately we want people to be honest, and the majority of the cases I get are. If that’s the case, then after the investigation the claim gets cleared and you are on your way.
So, basically, it’s not necessarily about proving exactly what happened, it’s about proving whether or not people are lying to us.