PLM Associates

Claims adjusters, appraisers, examiners, and investigators evaluate insurance claims. They decide whether an insurance company must pay a claim, and if so, how much.

Claims adjusters, appraisers, examiners, and investigators typically do the following:

• Investigate, evaluate, and settle insurance claims
• Determine whether the insurance policy covers the loss claimed
• Decide the appropriate amount the insurance company should pay
• Ensure that claims are not fraudulent
• Contact claimants' doctors or employers to get additional information on questionable claims
• Confer with legal counsel on claims when needed
• Keep claims files, such as records of settled claims and an inventory of claims requiring detailed analysis
• Negotiate settlements
• Authorize payments

What insurance adjusters, examiners, and investigators do varies by 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 to 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. 

Some claims adjusters work as self-employed 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.

Sometimes, self-employed adjusters are hired by insurance companies in place of hiring adjusters as regular employees. In this case, the self-employed adjusters work in the interest of the insurance company.

Adjusters inspect property damage to determine how much the insurance company should pay for the loss. The property they inspect could be a home, a business, or an automobile.

They interview the claimant and witnesses, inspect the property, and do additional research, such as look at police reports. Adjusters 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.

They gather information--including photographs and statements, either written or recorded audio or video--and put it in a report that claims examiners use to evaluate the claim. When the examiner approves policyholder's claim, the claims adjuster negotiates with the claimant 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.

Appraisers 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 review claims after they are submitted to ensure that proper guidelines have been followed by claimants and adjusters. They may assist adjusters with complicated claims or when, for example, a natural disaster occurs and the volume of claims increases.

Most claims examiners work for life or health insurance companies. Examiners 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 authorize 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 the applicants have no serious illnesses that would make them a high risk to insure.

Insurance investigators 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 claimants overstating 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 activities that would be ruled out by injuries stated in the claim.

Fire inspectors visit and inspect buildings and other structures, such as sports arenas and shopping malls, to search for fire hazards and to ensure that federal, state, and local fire codes are met. They also test and inspect fire protection and fire extinguishing equipment to ensure that it works. Fire investigators determine the origin and cause of fires by searching the surrounding scene and collecting evidence.

Fire inspectors typically do the following:

• Search for fire hazards
• Ensure that buildings comply with fire codes
• Test fire alarms, sprinklers, and other fire protection and extinguishing equipment
• Inspect equipment such as gasoline storage tanks and air compressors
• Review emergency evacuation plans
• Conduct follow-up visits when an infraction is found
• Confer with developers and planners to review plans for residential and commercial buildings
• Conduct fire and life safety education programs
• Keep detailed records that can be used in a court of law

Fire investigators typically do the following:

• Collect and analyze evidence
• Interview witnesses
• Determine the origin and cause of a fire
• Process and document evidence, such as photographs and diagrams
• Reconstruct the scene of a fire or arson
• Confer with other specialists, such as chemists, engineers, and attorneys, to analyze information
• Send evidence to laboratories to be tested for fingerprints or an accelerant
• Keep detailed records that can be used in a court of law
• Testify in civil and criminal legal proceedings

Unlike fire inspectors, many fire investigators have police powers and carry a weapon.

Forest fire inspectors and prevention specialists assess fire hazards in both public and residential areas. They look for issues that pose a wildfire risk and recommend ways to reduce the fire hazard. During patrols, they ensure that the public is following fire regulations and report fire conditions to central command.

Private detectives and investigators find facts and analyze information about legal, financial, and personal matters. They offer many services, including verifying people's backgrounds, tracing missing persons, investigating computer crimes, and protecting celebrities.

Private detectives and investigators typically do the following:

• Interview people to gather information
• Do various types of searches, using a computer or non-computerized records  
• Conduct surveillance (looking for, following, or watching a person without that person noticing)
• Collect evidence to present in court
• Verify employment, income, and facts on a person's background
• Investigate computer crimes, such as identity theft and illegal downloads
• Help in cases of criminal and civil liability, missing-persons cases, and insurance claims and fraud

Private detectives and investigators typically work for individuals, attorneys, and businesses. Some have their own investigative agency.

Private detectives and investigators offer many services, based on clients' needs. They may perform pre-employment background checks or look into a charge that someone has been stealing money from a company. They might be hired to prove or disprove infidelity in a divorce case.

Private detectives and investigators use a variety of tools when researching the facts in a case. Much of their work is done with a computer, which allows them to quickly get information, such as records of a person's prior arrests, telephone numbers, social networking-site details, and emails.

They make phone calls to verify facts, such as a person's income and place of employment. They also interview people when conducting a background investigation.

Investigators may go undercover, pretending to be someone else to go unnoticed, to get information, or to observe a suspect.

Detectives also conduct surveillance when investigating a case. They may watch a site, such as the person's home or office, often from an inconspicuous location or a vehicle. Using photographic and video cameras, binoculars, and global positioning systems (GPS), detectives gather information on persons of interest. Surveillance can be time consuming.

Detectives and investigators must be mindful of the law when conducting investigations. They must have a good understanding of federal, state, and local laws, such as privacy laws, and other legal issues affecting their work.

However, as the legality of certain methods may be unclear, investigators and detectives must make use good judgment when deciding how to pursue a case. They must collect evidence properly, so that it can be used legally in court. 

The following are examples of types of private detectives and investigators:

Computer forensic investigators specialize in recovering, analyzing, and presenting data from computers for use in investigations or as evidence. They may be able to recover deleted emails and documents.   

Legal investigators help prepare criminal defenses, verify facts in civil law suits, locate witnesses, and serve legal documents. They often work for lawyers and law firms.

Corporate investigators conduct internal and external investigations for corporations. Internally, they may investigate drug use in the workplace or ensure that expense accounts are not abused. Externally, they may try to thwart criminal schemes, such as fraudulent billing by a supplier.

Financial investigators may be hired to develop confidential financial profiles of individuals and companies that are prospective parties to large financial transactions. These investigators often are certified public accountants (CPAs), who work closely with investment bankers and other accountants. For more information, see the profile on accountants and auditors. Investigators also might search for assets to recover damages awarded by a court in fraud and theft cases.

Store detectives, also known as loss prevention agents, catch people who try to steal merchandise or destroy store property. 

Hotel detectives protect guests from theft of their belongings and preserve order in hotel restaurants and bars. They also may keep undesirable individuals, such as known thieves, off the premises.