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Insurance fraud occurs when someone files a false or fabricated claim with an insurance company. Such a claim may be submitted to any type of insurance agency including auto, home, or medical. Insurance fraud jobs are used to evaluate these types of claims and to verify the validity of the report prior to payment. Investigations into insurance fraud can occur with both personal insurance policies and commercial insurance policies.
Personal insurance fraud jobs typically include positions such as private investigators, claims adjusters, and insurance investigators. Each of these fraud-related positions focus on insurance claims filed by individuals. Governments may also hire insurance fraud specialists to handle claims made by people or businesses that are covered by governmental policies. For instance, a person in the United States who is covered by Medicaid may have their medical claims reviewed by a government insurance investigator.
These insurance investigators will often gather information through activity checks, claimant surveillance, and fact-checking of the claim information. Fraud investigators tend to work in the field more often than in an office, which means extensive travel may be necessary at times. Once the information about the claimant, or the claim, is collected, the investigator usually files a report, and the claim will either be approved or denied based upon the investigation results. If a false claim has already been paid, the insured person may face legal ramifications.
Commercial insurance fraud jobs are often similar, and involve work that is very much the same as, personal cases. Business and accounting knowledge may be required, however, to calculate the net loss of income a business has suffered and the effect of any damage on future business profits. The insurance investigation of a business may also require extensive inventory checks to validate any claims of property loss.
Both personal and commercial insurance investigators must be comfortable with undercover surveillance. Insurance fraud jobs generally require investigators to obtain truthful information about the claimant without their knowledge, which can mean long hours spent watching a person or business. Patience is often an essential requirement.
If the investigation uncovers that a report is a false claim, an insurance lawyer may file suit against the claimant. Many major insurance companies employ a staff of fraud lawyers to handle all court cases. An insurance company may only choose to file a lawsuit if the claimant has received payment as a result of a false claim. If no payment to the insured has been made yet, a false claim is typically denied.