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Claims adjusters, appraisers, examiners, and investigators
Published on: Monday, October 11, 2021
By: K Krishnan
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STUDENTS who are interested in accounting and business, can explore careers in this challenging field.  

However, due to ignorance they never consider careers as claims adjustors, appraisers, examiners and investigators.  Today let us explore this industry. 

Example 1: When a car gets into an accident, there is bound to be damage for the car owner’s car and also the third party. Usually car owners take an insurance to protect their car and also the third party.  Claiming from insurance is not an easy task. All insurance companies follow standard rules and regulations. A police report has to be made. Next the insured needs to contact his insurance company to make a claim. The insurance company will engage a claims adjuster to assess the damage. An appraiser will recommend the cost of the damaged parts. Reports will be sent to the insurance company where an examiner will study the report. At times an investigator will be engaged to verify the cause of the damage. If the person driving the car was drunk at the time of the accident, the insurance company can decline to pay. So, there are so many people who will be involved. This is only a car accident.

Example 2: What if lives were lost? What if they were badly injured? What if there was a fire, flood or earthquake? What if it was a robbery? Each case is dealt differently.   

The people involved would have varying duties, depending on the type of insurance company they work for. They must know a lot about what their company insures. 

For example, workers in property and casualty insurance must know housing and construction costs so that they can properly evaluate damage from floods or fires. Workers in health insurance must be able to determine which types of treatments are medically necessary and which are questionable. Let us look at the various roles they play. 

Adjusters

They inspect property damage or personal injury claims to determine how much the insurance company should pay for the loss. They might inspect a home, a business, or an automobile.

Adjusters interview the claimant and witnesses, inspect the property, and do additional research, such as look at police reports. They may consult with other workers, such as accountants, architects, construction workers, engineers, lawyers, and physicians, who can offer a more expert evaluation of a claim.

Adjusters gather information – including photographs and statements, either written or recorded on audio or video – and put together a report for claims examiners to review. When the examiner approves the claim, the adjuster negotiates with the policyholder and settles the claim.

If the claimant contests the outcome of the claim or the settlement, adjusters work with attorneys and expert witnesses to defend the insurer’s position.

Some claims adjusters work as public adjusters. Often, they are hired by claimants who prefer not to rely on the insurance company’s adjuster. 

The goal of adjusters working for insurance companies is to save as much money for the company as possible. The goal of a public adjuster working for a claimant is to get the highest possible amount paid to the claimant. They are paid a percentage of the settled claim.

Appraisers 

They estimate the cost or value of an insured item. Most appraisers who work for insurance companies and independent adjusting firms are auto damage appraisers. They inspect damaged vehicles after an accident and estimate the cost of repairs. This information then goes to the adjuster, who puts the estimated cost of repairs into the settlement.

Claims examiners 

They review claims after they are submitted to make sure claimants and adjusters followed proper guidelines. They may help adjusters with complicated claims or when, for example, a natural disaster occurs and the volume of claims increases.

Examiners 

They who work for health insurance companies review health-related claims to see whether the costs are reasonable, given the diagnosis. After they review the claim, they authorise appropriate payment, deny the claim, or refer the claim to an investigator.

Examiners who work for life insurance companies review the causes of death and pay particular attention to accidents, because most life insurance companies pay additional benefits if a death is accidental. Examiners also may review new applications for life insurance policies to make sure that the applicants have no serious illnesses that would make them a high risk to insure.

Insurance investigators 

They handle claims in which the company suspects fraudulent or criminal activity such as arson, staged accidents, or unnecessary medical treatments. The severity of insurance fraud cases varies, from overstated claims of vehicle damage to complicated fraud rings. 

Investigators often do surveillance work. For example, in the case of a fraudulent workers’ compensation claim, an investigator may covertly watch the claimant to see if he or she does anything that would be suspicious based on injuries stated in the claim.

Important Qualities

Students interested in venturing into this field must have the following qualities:
  • Analytical skills. Adjusters and examiners must each evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay. Adjusters must consider various pieces of information to reach a decision.
  • Communication skills. Claims adjusters and investigators must get information from a range of people, including claimants, witnesses, and medical experts. They must know the right questions to ask in order to gather the information they need.
  • Detail oriented. Adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences.
  • Interpersonal skills. Adjusters, examiners, and investigators often meet with claimants and others who may be upset by the situation that requires a claim or by the settlement the company is offering. These workers must be understanding, yet firm regarding their company’s policies. Source adapted from BLS, USA)


For further information

Those interested in learning more about this field can contact THE MALAYSIAN INSURANCE INSTITUTE. They conduct formal courses and training programs. For further details visit: 

The Malaysian Insurance Institute 

No 5, Jalan Sri Semantan Satu, 50490 Damansara Heights, Kuala Lumpur

Tel: 03-2087 8882 Fax : 03-2092 1501

Website: www.insurance.com.my





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