Claims adjusters, appraisers, examiners, and investigators typically do the following:
Claims adjusters, appraisers, examiners, and investigators 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.
Adjusters 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 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 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 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 that 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 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.
A high school diploma or equivalent is typically required for a person to work as an entry-level claims adjuster or examiner. However, employers sometimes prefer to hire applicants who have a bachelor’s degree or some insurance-related work experience.
For investigator jobs, a high school diploma or equivalent is the typical education requirement. Some insurance companies prefer to hire people trained as law enforcement officers or private investigators, because these workers have good interviewing and interrogation skills.
Auto damage appraisers typically have either a postsecondary nondegree award or experience working in an auto repair shop, identifying and estimating the cost of automotive repair. Many vocational schools and some community colleges offer programs in autobody repair that teach students how to estimate the cost of repairing damaged vehicles.
Licensing requirements for claims adjusters, appraisers, examiners, and investigators vary by state. Some states have few requirements; others require either completing prelicensing education or receiving a satisfactory score on a licensing exam (or both). Jobseekers should verify the licensing laws with the state and locality in which they want to work.
In some states, claims adjusters employed by insurance companies do not have to become licensed themselves because they can work under the company license.
Public adjusters may need to meet separate or additional requirements.
Some states that require licensing also require a certain number of continuing education credits per year to renew the license. Federal and state laws and the outcomes of claim disputes adjudicated in court affect how the claims must be handled and what insurance policies can and must cover. Examiners working on life and health claims must stay up to date on new medical procedures and prescription drugs. Examiners working on auto claims must be familiar with the most recent car models and repair techniques. To fulfill their continuing education requirements, workers can attend classes or workshops, write articles for claims publications, or give lectures and presentations.
The National Insurance Producer Registry (NIPR) provides information about state licensing requirements.