Claims Investigator

 

What does this person do?

Among the career paths in insurance, Claims Investigators fill a private detective role. They examine the facts of a claim to determine if the claim is valid. They assist insurance claims adjusters and insurance claims examiners in cases where fraud or criminality is suspected, especially if the claim is large. They decide the extent and validity of a claim. Claims Investigators also:

  • Coordinate the services that may be required by policy holders following an incident
  • Help insurance companies to settle claims quickly
  • Use a combination of tools including interviews and cutting-edge software to help evaluate claims
  • Investigate defective products that may cause injury or damage, or may investigate events (such as an oil spill) for which a company may be liable
  • Prepare reports, maintain records and keep track of evidence trails and interview statements

Claims investigators and forensic specialists have the option of being independent consultants, working for a variety of government and public organisations or working for insurance companies.

Among the classic types of fraud that they investigate are:

  • Accidents staged for profit
  • Claims of injury or disability
  • Arson (the criminal act of setting fire to a property on purpose) for profit
  • Inflated values claimed on lost, damaged or destroyed property
  • Claims for stolen items that actually were hidden, sold or given away
  • Losses deliberately created through neglect or recklessness
  • Patterns of repeated excessive billing by contractors, repair shops and medical providers
  • Claims on life insurance policies obtained with inaccurate representations, such as faked medical results
  • Claims on life insurance policies where the deceased disguised suicide as an accident or murder
  • Claims on life insurance policies where a beneficiary intentionally caused the death of the named insured
  • Claims entered by impostors posing as the named insured or beneficiary

These are just some of the possible scenarios in which, if suspected by other members of the claims department, an insurance investigator will be assigned the case.

 

Personality Traits

Insurance investigators, as a category of private detective, must have a combination of analytic and people skills to succeed. They must know where to find the information that they need and how to get it. They must be able to persuade other people to cooperate with their investigations, even when they have no compelling interest to do so. They know how to interpret the data that they uncover, and draw its relevance to the case at hand. Also they have the following skills:

  • Exceptional interpersonal skills and are naturally inquisitive
  • A sense of mutual respect and fairness and highly value ethical behaviour
  • Good decision-making skills and work well within a team
  • A reputation beyond reproach, with a keen interest in civil law, insurance law, rules of evidence and procedure

 

Learning Path

Educational requirements vary greatly, depending on the position and the employer. Normally, a bachelor’s degree is sufficient. Previous work experience is even more important.

There are no formal certification processes, but many larger insurance companies have in-house training programs. Insurance claims adjusters and insurance claims examiners sometimes make the transition to being insurance investigators. Otherwise, insurance investigators often have experience as private detectives or as law enforcement officers. Here are more learning paths:

Path One:

  1. National Senior Certificate with Mathematics AND Accounting OR Economics OR Business Studies
  2. In-service Training – Short courses, skills programs and on-the-job training are offered by employers.

Path Two:

  1. Further Education and Training Certificate NQF Level 3 or Grade 11 (Communication and Mathematical Literacy at NQF Level 3 are required.)
  2. Learnership – Short / Long Term Insurance Level 4

Path Three:

  1. Further Education and Training Certificate NQF Level 3 or Grade 11 (Communication and Mathematical Literacy at NQF Level 3 are required.)
  2. Learnership – Medical Claims Assessing Level 4

Path Four:

  1. National Senior Certificate
  2. IISA Programs in Insurance
  3. Designation: Fellow of the Insurance Institute of South Africa (FIISA)
  4. Workplace experience
  5. Certificate in Short Term Insurance
  6. Designation: Licentiate of the Insurance Institute of South Africa (LIISA)
  7. Workplace experience
  8. IISA Programs in Advanced Insurance Practice
  9. Designation: Associate of the Insurance Institute of South Africa (AIISA)
  10. Workplace experience
  11. IISA Programs in Risk Management
  12. Designation: Fellow of the Insurance Institute of South Africa (FIISA)

 

Employment Avenues

SA Police Service

Insurance Companies

Self-employment, with own private investigation office