Having an insurance policy minimises your losses in the event of an accident, but that’s only if your insurance claim is successful. Here is everything you need to know about how insurance companies investigate claims so you can ensure a successful insurance claims process in the future.

What is an Insurance Claims Investigation?

After receiving a claim, your insurer may have its insurance investigators look into your submission. The claims investigation process involves examining the details of your claim to determine its authenticity. If the insurance investigator determines that your request is invalid or fraudulent, your insurer may not accept your claim.

The insurance claims examination process relies on evidence gathered from the accident scene, records, and interviews to determine a claim’s legitimacy. Aside from determining validity, the enquiry also helps a claims adjuster decide how much to pay a claimant.

What are the Types of Claims Insurance Companies Investigate?

Illegitimate claims cost insurance companies over a billion pounds each year. According to Statista, in 2019 alone, the UK had around 760,000 fraudulent claim cases. The insurance investigation process helps insurers separate genuine claims from the false ones.

Types of claims insurers investigate include:

Property Damage Claims

Homeowners, business owners, and landlords submit property damage claims. The size of the claim varies according to the extent of the damage and the property type. If the claim is substantial, the insurance company will hire an expert to evaluate the damage to the property, its cause, and other details. The enquiry’s findings will determine how the insurance company proceeds with the claim.

Theft Claims

You can make a theft claim if someone has stolen or attempted to steal and damaged your insured property. The theft may be a burglary, hijacking, or robbery.

Personal Injury Claims

Victims of car accidents and other mishaps can submit a personal injury claim to receive compensation for injuries. The claim investigation will look into the cause of the victim’s car accident to determine their eligibility for compensation. A personal injury claim is fraudulent if the investigator discovers that the vehicle accident and damages were fictitious.

Workers’ Compensation Claims

Employees who sustain injuries in the workplace can get compensation by submitting a workers’ comp claim. This compensation will pay them for the time they spend out of office.

The claim will not be successful if:

  • The employer does not possess workers’ compensation insurance
  • The injured worker is not an actual employee
  • The worker’s injury or illness is not work-related

Healthcare/Medical Fraud Claims

Medical practitioners get paid by submitting healthcare claims to the patient’s insurance company. Fraud occurs when the practitioner or patient inflates medical treatment expenses and pockets the excess compensation.

insurance claims

What is an Insurance Company’s Claims Investigation Process?

Your insurance company starts investigating your claim not long after you submit it. The investigator may be an auditor or legal professional working on behalf of the insurer.

An investigator collects details about the incident/accident related to a claim by interviewing the claimant and witnesses. They will also start gathering physical evidence from the accident scene. If vehicles were involved, they might want to see each car to assess the case. The investigator may also acquire documentary evidence from police and medical reports and other sources.

If the claim is for a large sum, the insurance company may appoint a loss or claims adjuster to investigate the claim. A claims adjuster will look into the cause of the claimant’s loss and determine whether their insurance covers that loss.

To protect your interests, it is wise to hire a loss assessor. These services are especially helpful if the insurance company brings in an adjuster.

A loss assessor like Property Claim Assist provides advice and ensures proper representation throughout a claim investigation. We will provide a strategy that increases the likelihood of the enquiry ending in your favour and ensures that you receive satisfactory compensation.

When the enquiry is over, the investigator will provide the insurer with a case report that details their findings. The insurance company will use this case report to determine how to proceed with a claim and the settlement amount to offer.

What Do Insurance Investigators Ask?

During the claim investigation process, expect the insurance fraud investigator to look into the following:

Incident Overview

The claim investigator will start examining the claimant’s case by putting together a summary of the claim. The summary will contain a short description of the claim and the time, date, and location of the incident/accident.

Claimant Interview/Statement

The insurance adjuster will interview the claimant and get a verbal or written statement regarding the incident. The interview is meant to get every detail about the incident/accident from the claimant’s perspective.

Documentary Evidence

Do car insurance companies check police reports? They absolutely do.

The adjuster will verify the claimant’s story by comparing it to details gathered from various documentary evidence. Insurance companies check police reports, so your description of the incident should match up.

Given this, make sure to contact the police to file an accident report if the situation warrants it. A police report is crucial for determining what happened and verifying if the submitted claim is fraudulent. Without one, you lose critical support for your claim.

Other useful documentary evidence that facilitates the insurance claim investigation process are:

  • Medical and accident reports
  • Photos
  • Receipts
  • Inventory records
  • Bills of sales
  • Deeds
  • Appraisals
  • Diagrams
  • Proof of ownership
  • Video recordings

Physical Evidence

Physical evidence used when investigating insurance claims include fingerprints, the damaged property, computer hard drives, and DNA. Investigators will examine the evidence thoroughly to ensure and has not been substituted. Tampering with physical evidence can void your claim and may even lead to prosecution.

Witness Statements

People who saw the car accident or other incident that led to your loss can provide useful insights that support or discredit your claim. Conflicts between your story and a witness’s testimony will require further investigative probing.

Survey the Area and Suspect

Property damage and car insurance claim investigations require taking photos and videos of the accident scene and the claimant’s loss. The investigator will compare the images to statements and official records to find discrepancies. Monitoring the claimant to confirm they are not lying about their accident and loss may also be necessary.

Obtain Other Contextual Information

How far back do insurance companies look for incidents/accidents? Investigators are very thorough and will look into every possible detail when examining insurance claims.

For instance, the investigator may survey all the claimant’s social media accounts to learn more about their situation. The enquiry will also dig into the claimant’s past to check if they made similar claims before and were successful or unsuccessful.

You Must Give Complete Information About Your Losses

After receiving your home or car insurance claim, your insurance company will start verifying the details of your claim. The company will also look into if the request meets the requirements of your insurance policy.

Prevent delays and other complications by being cooperative and offering honest answers from the start. If you have photos or other proof that substantiate your claim, make them available to boost the likelihood of success.

Requests for Personal Information

Whether you or someone else is at fault in a property or car accident, expect a call from the insurance adjuster. As part of the insurance claims process, the adjuster will ask for your personal information, such as your address, full name, date of birth, health insurance company, primary care doctor, and so on.

The insurance company will enter all the information you provide into a national database that contains details about:

  • Past and current insurance contracts
  • Prior claims
  • Injuries sustained in previous car accidents and more

If the information you provided contradicts what is in the database, it will indicate fraud and might hamper your claims process. Likewise, if your information indicates that a previous accident may have caused your current injuries, the money offered by your insurance company may be lower than expected.

Protect your interests and privacy by talking to a solicitor before providing your personal information to an insurance adjuster. Seeking legal advice is especially important if you were at fault in the accident.

Information from Third Parties

The insurance company may also request information from anyone aware of the accident. Third parties that the investigating team might contact are the claimant’s friends and family members. The third-party does not have to be a beneficiary of the claimant’s insurance policy.

You have to provide the adjuster with the names and contact details of anyone capable of providing information relevant to your claim. However, it is not your duty to compel anyone to answer questions from the insurance adjuster.

The insurers cannot refuse to pay a claim based on a third party refusing to answer questions.

Note that having a third party cooperate with the adjuster can be in your favour if they possess information relevant to proving your loss.

Insurance Fraud Investigations

Insurance scams increase the cost of insurance for insurers, claimants, and everyone else. To preserve their bottom line, insurers have to make sure that a claim is legitimate before offering compensation.

Property damage, car accident, and personal injury all require claims investigation services. Without it, determining the at-fault person and who deserves compensation is difficult.

Fraud occurs when a person tries to get compensation from an insurance policy by deception. For instance, a fraudulent home insurance claim may involve deliberately damaging one’s insured house and making a claim. Falsifying the cause of losses, who is at-fault for damages, or exaggerating the extent of your losses are all also forms of insurance scams.

Such scams can lead to losing your insurance claim and policy or even serving jail time. The burden of proof is on the insurance provider to prove an insurance fraud allegation. Property and vehicle insurance companies prove fraud by showing that the claimant has not acted with the utmost good faith and intended to deceive the insurer.

The steps involved in checking for fraud are:

  • Collecting statements by interviewing the victim and witnesses
  • Reviewing documents, such as a medical or police report regarding the incident
  • Visiting the location of the accident to take photos and view the scene
  • Monitoring the claimant online and offline to determine if their claimed damage or injury is true
  • Checking the claimant’s insurance history for past cases of fraudulent claims

An insurance investigator can also get tip-offs from third parties reporting a false insurance claim. It is best to report a suspected insurance scam directly to the insurer or the Insurance Fraud Bureau (IFB).

how insurance companies investigate claims

How Long Does an Insurance Claim Investigation Take?

After filing a claim for property or car insurance, expect to hear from the insurance adjuster within one to three days. It may take longer if the adjuster has to inspect the alleged damage.

The time needed to investigate a claim depends on your insurer, location, and the circumstances of your claim. Insurance claim examinations typically take weeks while some can last for months.

You can speed up the process by:

  • Filing your claim as soon as possible
  • Providing accurate information and pertinent evidence when you submit your claim
  • Cooperating with the insurance investigator

Some factors that may delay your claim or lead to an undesirable outcome are:

  • Poor communication between you and the insurance adjuster
  • Providing the wrong contact information when filing a claim
  • Not understanding how much coverage your insurance offers
  • Insufficient money to cover your deductible
  • Delays in gathering medical evidence, police report, or other documentary evidence
  • The other party to the claim is contesting liability
  • The other party to the claim is anonymous

While waiting for the insurance company to process your claim, the defendant or their insurance company may offer you compensation. The initial offer is usually a low one.

Before you accept, talk to our loss assessor team. We will guide you towards getting the highest compensation possible.

What if the Investigation is Taking Too Long?

When people submit an insurance claim, they usually urgently need the money to get their life back on track. For example, a car insurance claim might mean having a reliable vehicle or relying on public transport. If the insurance claims process is taking too long for any reason, you have options.

Section 13A of the Enterprise Act 2016 requires that insurers process and pay claims in a “reasonable time” but does not explicitly state how long a reasonable time frame is. Instead, it depends on “all the relevant circumstances,” such as the type of claim, the complexity of the case, regulatory requirements, and any aspects outside the insurer’s control.

If you feel the claim processing is taking too long, take advantage of your insurance company’s complaints process. Details on how to use the complaints process should be available in your insurance contract or on your insurer’s website.

The insurer’s internal compliance & complaints team is usually responsible for answering delay queries. If the outcome of submitting a formal complaint is unsatisfactory you can complain to the Financial Ombudsman Service although this process can take several months.  Your solicitor can help you with this and other complaint processes.

What If I Disagree with the Insurance Company’s Decision?

Some people want to know how to fight a negative insurance claim decision. The first thing to remember is to be calm and polite. Politely disputing the insurance company’s decision increases your chances of getting a favourable outcome.

Below are the steps to follow:

  1. Start by hiring a loss assessor like Property Claim Assist that has experience getting clients the best possible settlement.
  2. They will read the fine print of your coverage to verify your insurance coverage and how much compensation you should get. Our experts can explain your insurance contract and recommend the best way to proceed with your complaint.
  3. They will review the claim with your insurance company to make sure all the details are correct.
  4. Have your loss assessor write a polite and detailed letter to the insurance adjuster. The letter must state why you disagree with the insurer’s conclusion. You should hear from the adjuster within 10 to 14 days.
  5. If none of the above gets results, have your solicitor file a report to the Financial Ombudsman Service (FOS). The FOS makes sure that customers receive fair treatment from insurance companies.

Can an Insurance Company Refuse to Pay a Claim?

An insurance company cannot refuse to pay your claim without telling you why. Some of the reasons why a claims process may fail are:

  • Your policy was not active when the incident related to the claim occurred.
  • Your policy is invalid because of false information or missing details in your insurance application.
  • Your insurance does not cover the damaged property.
  • An exclusion clause in your policy excludes the incident in your claim.
  • You failed to pay multiple premium instalments.
  • You did not inform your insurer about changes in your circumstances.
  • You did not follow the proper claims process.
  • You exaggerated your loss or did not meet a policy condition.

Before challenging your insurer’s refusal to accept a claim, read through your insurance contract. If your policy shows that the insurance company’s decision is baseless, complain to the Financial Ombudsman Service.

You must submit your complaint to the FOS within six months of your insurer providing their final response. The FOS’s decision will be binding on the insurance company, but if you do not accept the body’s decision, you can take your policy provider to court.

Need help with your insurance claim? Contact Property Claim Assist today to schedule a consultation on your case and get professional advice from an experienced loss assessor.