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What is my car insurance claim being investigated for?

Here's what you need to know...

  • When claims are filed, they are assigned to claims adjusters who research the details.
  • Adjusters will interview you and will also speak with an adjuster representing the other parties involved to compare the stories of each side.
  • Your carrier’s claims adjuster will represent you and take charge of communications that deal with the claim.
  • Companies may send third-party estimators to assess damage and then submit photos to the insurer for review.
  • Upon review, insurers will compare the damage, photos from the scene, witness statements, driver statements and police reports to determine fault.

Start comparing car insurance rates now by using our FREE tool above! When auto insurance claims are filed, the carrier must determine who was at fault for the loss to determine which driver will be held responsible. While some states do operate under no-fault systems, where each company pays for their own policyholder’s damages, a majority of states use fault to determine which insurer will pay for damages and repairs. Fault is also used to determine who’s rates are going to go up in the future due to their negligence. This is why all insurers spend a great deal of time and resources investigating claims. If you’re interested in learning just what’s being investigated, read this guide to claims investigations:

Why Claims Investigations Are So Important

Claims are investigated for fault determination, future rate calculations, and also to detect fraud. Since insurers are in business to make money, they must take the appropriate steps to spot red flags and stop the payout on a claim that was staged or unfounded.

With insurance fraud being a major issue in the United States and fraudsters getting more creative over time, insurers are making bigger efforts to spot scams before the scammer gets paid. In fact, the National Insurance Crime Bureau reports that questionable claims have gone up 27 percent in recent years, showing investigations are more of a priority.

How can an adjuster spot insurance fraud when a claim is filed?

It can be difficult to spot a fraudulent claim on words alone, but records and data can be definite red flags to adjusters who are investigating both the claim and the claimant. One immediate red flag that signifies fraud is when there are discerning patterns in the claimant’s claim history. All adjusters will look for suspicious loss indicators that have been designated by the National Insurance Crime Bureau.

Common NICB Suspicious Loss Indicators

Not every suspicious loss indicator means the filer is guilty, but claims with common indicators will be more thoroughly investigated and scrutinized. Here are just some of the indicators you should be aware of as a claimant:

  • Claimants who report a large loss and are calm and not flustered
  • Claims submitted shortly after the named insured has increased coverage
  • Claimants who produce handwritten receipts or invoices for repairs of purchases
  • Fire claims reported shortly after members of the household left the property
  • Claimant is severely in debt and recently unemployed
  • Claims of significant injury but social media evidence proving otherwise

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What will you be asked when filing a claim initially?

When filing a claim, you’ll speak with a customer service agent who’ll ask you scripted questions. The answers that you give at this time will help adjusters and investigators to determine how deep they must delve throughout the claims process. Some claims appear to be much more obvious than others. Here are some of the questions that you’ll be expected to answer on the spot when filing your claim:

  • What day and time did the loss occur?
  • Where did the loss occur?
  • What were the road conditions/weather?
  • What is the name, phone number, address and policy number of other party involved?
  • Were there witnesses? Do you have the named and numbers?
  • Do you have a police report number?
  • Was the loss in an area with CCTV cameras?
  • Did anyone in the vehicle suffer injuries?
  • Did anyone seek immediate medical treatment?
  • What parts of your vehicle were damaged?
  • What parts of the other vehicles involved were damaged?
  • Did the other driver say anything about fault at the scene?
  • Where is the vehicle now? Was it operable or towed?
  • Do you have pictures of the scene or the damages to each vehicle?

Once the Claim is Forwarded to an Adjuster

It’s very important that you stick to the facts during your phone call. Never apologize or give your opinions on fault at the scene or on the phone with a third-party adjuster because this can affect the investigations. After you’ve answered all of the pertinent questions during your first phone call, the claim will be assigned to an adjuster who will start to run reports, conduct more thorough interviews, request documents, and review photos and bills. It’s during this time that the professional representing each claimant will look for red flags.

What types of reports can adjusters run to investigate my claim?

After the adjuster has reviewed your policy and the coverage available at the time of the loss, they will proceed to investigations. As a claim is being processed, several reports are run. The adjuster needs to investigate both the claimant’s history and record and the details of the loss. Here are some of the reports that property and casualty adjusters can use as they’re trying to get to a fair settlement:

  • Police report with witness statements
  • The claims history report of each claimant
  • An endorsement report showing recent changes made on the policy
  • The policyholder’s credit report and employment history
  • Civil and criminal search on each person
  • Medical records showing pre-existing conditions for injury claims
  • Car history reports showing prior damage sustained before loss
  • Damage reports showing estimates on repair costs
  • Value reports showing fair market value of the vehicle

When do private investigators get involved?

If the adjuster is convinced that a claim is fraudulent, they might go as far as to hire a private investigator to follow you. This is most common when you’re claiming serious injuries that could affect your quality of life. Make sure you realize this is a possibility if you’re tempted to exaggerate your injuries because the company could file fraud charges against you.

Insurers spend millions on claims payouts annually. To avoid spending more than projected, the company needs to weed through the claims and determine which are legitimate. If you’ve done business with a carrier that hasn’t been fair through the investigations process, it might be time to switch carriers. Use an online rate comparison tool and then find a company known for claims service and bargain pricing. Start comparing car insurance rates now by entering your zip code in our FREE tool below!

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