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Insurance Claims Fraud Consultant


When you receive a call from an insurance claims fraud consultant, don't fret, yet. Their job is to inspect all insurance claims to spot signs of fraud. Fraud happens when someone makes a claim based on false information, such as an inaccurate report, in the hopes of getting a claim check from the insurance company. Most insurance companies hire these professionals to look at claims as they come in, in order to minimize their risk. By understanding what they're looking for, you'll avoid problems with your claims.

Insurance Claims Fraud Consultant Looks for Fraud Indicators

These professionals spot claims that look suspicious. Their job is critical to the insurance industry, helping insurance companies avoid costly false claims. False claims and insurance fraud increases the cost of insurance to everyone else. Therefore, the consultant's job is an essential one to keep premiums low.

Some situations are more likely to be fraud than others are. Here are some circumstances consultants are looking for when a claim comes in.

  • Recent increases in the coverage just before filing the claim looks suspicious
  • An easy understanding or familiarity of the claim process could signal past filings and potential abuse
  • A history of claims with the company, filing multiple claims looks suspicious
  • A loss that happens just after getting the policy or just before it is about to expire could be a way to get the funds from the policy
  • Duplicate coverage, such as having two insurance policies from two different companies
  • Calling the insurance company to check on how much coverage or the state of the insurance policy right before a claim
  • You don't want to answer questions, or you avoid calls about the claim

Each of these is an indicator to an insurance consultant that there could be a fraudulent claim. Usually, an initial claims adjustor will notice these concerns and will report the findings to the fraud consultant to uncover the truth.

Commercial Loss

In commercial loss situations, a fraud consultant needs to find out what is happening in the business. They will look at situations before the claim is filed and just after. Is there a good explanation for the occurrence? For example, in fire loss claims, the consultant wants to see the report from the fire investigator showing the fire was not arson. A business struggling financially or in desperate need of money is a big sign of potential fraud to the consultant.

The consultant is also looking at the state of the business. They may look at the business's current success, any drops in business or the location of the business. If the business is suffering from a deteriorating neighborhood, for example, this may be an indication of a fraudulent claim. Is the business trying to get out of that neighborhood? When property is over insured, or the machinery within a business is no longer usable or is obsolete, a claim on that equipment may be suspect, as well.

Property Loss from Individuals

The insurance claims fraud consultant does not just look at businesses, but at personal claims too. If you file a claim on personal property, especially if the claim is large, chances are a consultant will come in and investigate.

Consultants look at claims in several ways. The largest indication of fraud happens where there are significant life changes happening. Examples may include marital difficulties, divorce, child support obligations, or separation. The claims also appear worrisome if there is a history of gambling or alcohol abuse in the family, particularly by the claim filer. Their basic question: does the family need this money for something other than repairing the home?

Property that's for sale is also a red flag for a consultant, particularly if the property has been on the market for some time. Other red flags include a drop in income, a lifestyle that is inconsistent with the way the person is living, or a loss of significant expensive items.

As a rule, keep a home inventory to prove your claims are accurate.

Why Is the Fraud Consultant Contacting You?

Often people are worried to hear a phone call from the insurance claims fraud consultant. When you file a claim, especially larger claims, it is standard practice have a consultant look at the claim before they will issue a check to cover your losses. This is generally standard procedure and not a need to worry.

For those who have filed a claim that is less than accurate, work with the consultant to insure that the claim's information is correct. The worst action you can take is no action at all. Follow up with the consultant to find out what they need, provide them with documents to substantiate your claim and always double check all claims for accuracy.

Insurance Claims Fraud Consultant