Unraveling The Investigative Process Of Insurance Adjusters

Insurance adjusters are professionals who handle insurance claims from the moment of filing until their resolution. They investigate cases, conduct negotiations, and decide on a fair settlement amount. While the specific nature of insurance investigations can vary depending on the individual claim, insurance adjusters typically follow a common series of investigative steps.

The first step in an insurance investigation is to open a file. Once a file has been opened, it is assigned to a claims adjuster, who will investigate the accident and negotiate a settlement. The adjuster will then contact the claimant – the insured person – to discuss the incident and learn about the extent of the damages and the evidence available.

The adjuster will also request official records, such as police reports and accident reports filed with the state department of motor vehicles. They will also investigate the injured party, looking for any negative information that could diminish the value of the claim. This includes checking social media accounts and medical records.

Insurance adjusters also conduct visual evaluations of the accident scene, assessing property damage in person. During this step, they may take official photographs of the damage and compare them to the original claim.

Finally, the adjuster will determine the value of the claim and negotiate a settlement. They will submit a full assessment to the insurance company, including a recommendation to deny or accept the claim. If the adjuster recommends approving the claim, they will provide an estimate of its value.

Contact the claimant to discuss the incident and learn the extent of damages

Contacting the claimant to discuss the incident and the extent of the damages is a crucial step in the insurance adjuster's investigation process. Here's a detailed guide on this topic:

Contacting the Claimant:

• When a "third-party" claim is made against their client's insurance policy, adjusters will contact the claimant or their legal representative to discuss the incident.
• This communication serves to gather information, clarify the circumstances, and understand the claimant's perspective.

Understanding the Incident:

• Adjusters will ask the claimant to recount their version of the events, providing as many details as possible.
• This includes information about the policyholder's actions, any witnesses present, and the resulting damages or injuries sustained by the claimant.

Assessing the Damages:

• The adjuster will request documentation related to the claim, including medical bills, proof of lost income, tax returns, and evidence of property damage.
• They will scrutinize these documents to verify the validity and extent of the claimed damages.
• Medical records are particularly important, as they can indicate the severity of injuries, previous injuries, and the claimant's overall health condition.

Analyzing Claimant's Background:

• Insurance adjusters use databases to check the claimant's history of personal injury claims.
• They may also perform a background check by searching for the claimant online or hiring an investigator to ensure the legitimacy of the claim.

Calculating Settlement Value:

• Adjusters assess two key factors: the claimant's likelihood of winning a potential lawsuit and the potential jury award for damages.
• Damages are categorized as either capable of exact calculation (medical bills and lost earnings) or non-exact calculation (pain and suffering).
• Medical bills and lost earnings are calculated mathematically, while pain and suffering are often determined using formulas and specialized software.

Making the Initial Settlement Offer:

• Once the settlement value is determined, the adjuster decides on the initial offer, which is typically a percentage of the perceived final value.
• This offer tends to be lower when dealing with unrepresented claimants, as they may not be aware of their entitlements.

In summary, contacting the claimant is a critical step in an insurance adjuster's investigation. It allows for information gathering, document verification, and assessing the validity and extent of claimed damages. Adjusters also analyze the claimant's background and calculate a settlement value before making an initial offer.

Request official records, including police reports and medical records

Official records, including police reports and medical records, can be requested by members of the public. The process for doing so varies depending on the type of record and the location.

Requesting Police Reports

In the United States, police reports are requested through local police departments. Some departments allow requests to be made online, by mail, in person, or by phone. Requests are typically processed in the order they are received and there may be a charge for obtaining copies of the records. The time it takes to receive a copy of a police report can vary from a few days to a few months, depending on the complexity of the request and whether the investigation is still ongoing. It's important to note that requests for sensitive information may be handled differently and could require additional steps for approval.

Requesting Medical Records

In the United States, individuals have the legal right to access and obtain copies of their medical records. This is ensured by the Health Insurance Portability and Accountability Act (HIPAA). Requests for medical records can often be made through a healthcare provider's online patient portal, by phone, email, or in person. The requestor may need to fill out a form and provide relevant information such as their name, date of birth, Social Security number, dates of service, and the specific records being requested. There may be a reasonable fee for obtaining copies of medical records, but providers cannot deny access due to unpaid medical bills. The time frame for fulfilling requests can vary, typically ranging from 30 to 60 days.

Requesting Military Service Records

In the United States, military service records can be requested from the National Personnel Records Center (NPRC) of the National Archives. Requests can be initiated online or by mail, and there is no charge for basic requests. However, there may be a fee for obtaining archival records, which are typically available to the public 62 years after the service member's separation from the military.

Requesting Open Records

Open records refer to government documents and information that are accessible to the public. In the United States, requests for open records can be made to the relevant government agencies at the federal, state, or local level. Each state has its own laws and procedures for open record requests. At the federal level, the Freedom of Information Act (FOIA) governs the process for requesting records from federal agencies. It's important to first check if the desired information is already publicly available before submitting a request.

Investigate the claimant's history and social media for any negative information

When investigating a claim, insurance adjusters will often look into the claimant's history and social media presence for any negative information that might reduce the value of the claim or justify denying it. This can include searching for information on public websites such as social media profiles, Yelp, TripAdvisor, and Google+.

In the case of social media, adjusters will look for posts that might indicate a level of fitness inconsistent with a medical diagnosis or accident history. They might also search for photos or status updates that show how an accident has or hasn't affected the claimant's life. For example, if a claimant has stated that they suffered an intense shoulder injury in a car accident, but the adjuster finds a video of them playing basketball the day after the accident, this could indicate fraud.

Adjusters will also look at a claimant's history of previous property damage or personal injury claims, as well as their financial situation. They might check for liens against property, recent bankruptcy filings, or other signs of financial trouble, which could indicate a motivation to commit fraud.

It is important for claimants to be mindful of what they post on social media, as information revealed publicly may be taken out of context and used against them.

Conduct a physical evaluation of the property damage and take photographs

When it comes to property damage, insurance adjusters are tasked with evaluating the extent of the damage and estimating repair costs. They conduct a thorough inspection of the property, assessing both structural damage and damage to personal belongings.

• Full Inspection of Damaged Property and Items: Adjusters inspect any damage to the property, including the home and other structures such as a garage, tool shed, or swimming pool. They verify that the damage is legitimate and related to the incident in question. For example, in a claim for hail damage to a roof, they ensure that the damage occurred during the recent hailstorm and not years ago.
• Inventory of Damaged or Destroyed Items: Adjusters may request a list or inventory of damaged items, including receipts. Policyholders are usually advised not to dispose of damaged items until the adjuster has completed their evaluation. Taking photographs or videos of the damaged items is crucial, as it provides visual evidence to support the claim.
• Structural Damage Assessment: Adjusters pay close attention to structural damage and may recommend hiring a licensed engineer to inspect the property if needed. They look for cracks in walls, damage to floors or ceilings, and missing roofing tiles, among other issues.
• Signs of Fraud or Intentional Damage: Adjusters are trained to look for signs of insurance fraud, such as intentional damage or pre-existing damage from a previous incident. They want to ensure that damage claims are legitimate and not exaggerated or falsified to receive higher compensation.
• Contextual Photographs: Taking photographs is an essential part of the process. Adjusters require visual proof of damage, including contextual information such as the location of the damage, the extent of the affected area, and counts of materials like window screens. Photographs help adjusters quickly approve supplement items and ensure that all necessary repairs are identified.
• Avoiding Common Mistakes: It is important for adjusters to take enough photographs to paint a complete picture of the damage. However, submitting too many photos can overwhelm the adjuster and slow down the review process. Striking a balance is crucial to creating a seamless negotiation process.

By following these steps, insurance adjusters can effectively investigate property damage, determine the validity of claims, and estimate repair costs.

Determine the validity and value of the claim, then negotiate a settlement

When a claim is filed, an insurance adjuster is assigned to the case to determine its validity and value, and negotiate a settlement. The adjuster will go over the details of the case and gather documentation, including official records such as police reports and medical records. They will also interview the claimant and any witnesses, inspect the property damage, and conduct additional research. The adjuster's goal is to assess the validity and extent of the claim and determine whether the insurance policy covers the loss. They will look for any evidence of fraud or exaggeration and try to find information that could lower the value of the claim.

During the investigation, the adjuster may request access to the claimant's medical records and social media accounts. It is important for the claimant to be cautious about what information they share and consider seeking legal advice before providing access to personal records. The adjuster may also ask the claimant for a recorded statement, but it is generally not in the claimant's best interest to provide one without legal representation.

Once the adjuster has gathered all the necessary information, they will submit a full assessment to the insurance company, including a recommendation to deny or accept the claim. If the claim is accepted, the adjuster will provide an estimate of its value. The insurance company will then review the recommendation and make a determination. If a settlement is offered, negotiations can begin. It is important to note that the initial settlement offer is often lower than what the claimant may be entitled to, and negotiation is typically necessary to reach a fair outcome.

Throughout the process, it is crucial for claimants to protect their rights and seek legal assistance if needed. Insurance adjusters work for the insurance company and their goal is to minimise payouts. Having a personal injury lawyer can help level the playing field and ensure that the claimant's interests are protected during negotiations.

Frequently asked questions