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What Does an Insurance Claim Examiner Do?

Jeremy Laukkonen
Jeremy Laukkonen

The title of insurance claim examiner can describe a few different occupations within the various insurance fields. This job title is similar, and sometimes even interchangeable with, the term insurance adjuster, though examiners typically work in health and life insurance while adjusters are in property insurance. In cases where the term insurance adjuster is used, senior adjusters will sometimes be referred to as insurance claim examiners. Each of these different jobs has a similar set of responsibilities, such as investigating and verifying claims, evaluating individual cases and negotiating settlements. An insurance claim examiner will typically work normal office hours in a fixed location, though they can also be required to travel in certain cases.

When an insurance claim is filed, there is a process it must go through before the claimant can receive any payment. The exact process can differ from one insurance field to another, though there is typically some attempt to verify the claim and then determine how much money should be paid out. Many parts of this process are carried out by an insurance claim examiner or adjuster.

Claims examiners review insurance claims.
Claims examiners review insurance claims.

The term insurance claim examiner is most commonly used to describe people who work in the health and life insurance industries. Health insurance claim examiners commonly look at medical claims to verify whether the requested charges are in line with the diagnosis that was received. In order to accomplish this, they typically work with rubrics and guidelines that can provide the costs of treatments, the average length of a hospital stay for a given condition and various other data. They often consult with experts and perform research to determine the veracity and severity of different claims.

Insurance claim examiners who work in life insurance perform similar duties, though they are usually focused on verifying cause of death. Since some policies do not pay out for deaths caused by certain conditions, an insurance claim examiner can be responsible for determining whether to accept a claim. Both health and life insurance claim examiners are responsible for accepting or denying claims, and can also issue a request for an investigator to look into a case.

Property insurance firms typically refer to the people who examine claims as adjusters. When one of these insurance companies does employ claim examiners, they are typically in a supervisory position. In some cases, a property or casualty insurance adjuster will refer a particularly complex case to a senior claim examiner. Other property and casualty examiners simply review claims that have been approved or denied by adjusters to verify that all of the correct procedures were followed.

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    • Claims examiners review insurance claims.
      By: emiliezhang
      Claims examiners review insurance claims.