Comprehensive Guide to Insurance Investigations Services in Houston

What Is an Investigation Into an Insurance Claim?

Insurance companies often look into claims to see if they are real. The claims adjuster can make a smart choice about how to move forward with a claim thanks to the Insurance Investigations Services in Houston.

Investigations into insurance claims are done to stop the spread of false or exaggerated claims. An illegitimate claim is one that is not true or fair, and finding it early can save you a lot of money by stopping insurance claim fraudsters from getting away with it.

Insurance claim investigators are very important for finding and stopping fraud and making sure that only real claims are approved. For example, think about a policyholder who files a claim for personal injury after getting into a car accident. To confirm the details of the incident, an insurance claim investigator may look at surveillance footage, talk to witnesses, and look at medical records. In one case, the investigator finds that the claimant's statements and evidence don't match up, like the fact that there were no reported injuries right after the accident. The investigator helps the insurance company avoid paying out a lot of money on a fake claim by finding these kinds of differences. This protects the integrity of the claims process.

To decide if an insurance claim is real or fake, investigators look at evidence, talk to people, and look at records.

Types of Insurance Claims That Are Looked Into: Main Areas of Interest

Looking Into Claims for Workers' Compensation Insurance

Fraudulent workers' compensation claims can hurt your business's finances. An examiner will look into a workers' compensation claim to see if it is real.

The Insurance Investigations Services in Houston wants to find out two things:

Is the worker really hurt as badly as they say they are?

Did the person get hurt while they were working?

For instance, if an employee gets hurt outside of work on Tuesday night but comes in the next day and files a claim saying the injury happened at work, they would be filing a fake workers' comp claim. It would be best if an Insurance Investigations Services in Houston found that lie.

Fraud in Personal Injury and Insurance Investigations Services in Houston

Fraudulent claims for personal injury can be just as dangerous as claims for workers' compensation that are also false.

You can file a personal injury claim against a business or against someone else. When the victim actually fell on their own icy steps but made it look like it happened in front of a store, the claim is false.

 Claims for Theft and Damage to Property

Insurance companies will also look into claims for theft (like theft, burglary, hijacking, or robbery) and property damage (like fire damage, water damage, or car accidents).

An investigator might call in an expert if the property and the claim are right. For instance, they might ask someone to come in and look at the burn patterns to find out where the fire started and what caused it.

The examiner will be able to either confirm or deny that the claim is valid based on the information they get from this process.

Claims of Fraud in Healthcare or Medicine

Both private and public insurance companies, like Medicare and Medicaid, look into claims of medical fraud. Both the doctor and the patient can make fake or inflated healthcare claims, and sometimes they do it together to make money.

The Legal Information Institute says that statistics now show that 10 cents of every dollar spent on healthcare goes to paying for false healthcare claims. These scams hurt not only the insurance companies but also other customers, because fraud makes insurance plans more expensive to cover the losses.

A Step-by-Step Guide to the Insurance Investigations Services in Houston

The Insurance Investigations Services in Houston process is like other investigations in some ways. There are a lot of steps involved, like gathering and reviewing documents, getting statements, finding and interviewing witnesses, inspecting and photographing the damaged property or accident site, watching people, looking at social media accounts, and reporting insurance fraud.

 Gathering and Looking Over Papers

During your Insurance Investigations Services in Houston, ask for and gather official records that relate to the injury or damage.

For a personal injury claim, you can seek out official records created by the hospital or victim’s physician. Ask for medical release forms, prescription records, doctor's notes, or any other paperwork that could prove the injury is real and serious.

Ask for the same things for workers' comp claims and the OSHA form that describes the accident.

If you want to file a claim for property damage from a car accident, ask for a copy of the police report and the accident report. These reports will have information from the day the accident was reported and can be used to back up what people said and what they said in interviews.

If you are making a claim for stolen property, ask for receipts for the stolen item or pictures that show it belonged to the victim. Sometimes a real victim of property theft will add things to their claim that they didn't really own. Requesting proof of these things will help keep people from making false insurance claims.

 How to Use Interviews to Find Insurance Fraud

One of the best ways to get information during an insurance claims investigation is to talk to the victim, witnesses, and, if necessary, the person who did it.

The questions you ask will change depending on the claim. If you want to file a theft claim, ask what was stolen, when the person first noticed something was wrong, and the names of any people who were in the house at the time of the theft. Read the original police report out loud and pay attention to how the person who is claiming responds.

Ask everyone involved to give you a written or recorded account of what happened and the circumstances. It will be easier for you to compare new information to what was said if you can hear or read the statement again later.

Surveys and Ways to Find Things On-Site

Take pictures or videos that will help the story make sense. Take pictures of the place where the injury happened (workplace, home, car, intersection) and the injury itself, depending on the claim. Being able to see the environment in person all the time will help you understand what the statements and official records say.

You might also want to keep an eye on things. If an employee says they hurt their back after slipping on the icy steps of the hardware store, watch how they spend their time after that. Did you see them walk into the dance studio? Did they buy a dining table and put it in their truck themselves?

Getting More Information About the Situation

Lastly, think about other information that will help you understand the claim in its context.

To find out more about the person and the situation, look at their social media accounts. If you recently posted about having money problems or hating your job, people might be suspicious. Posts about playing sports might make an injury claim seem less believable.

Find out if they have made claims in the past. Have they told that story before? Did the last investigation into insurance claims show that the claim was false? This kind of discovery could change the course of the investigation.

What Happens If You Commit Insurance Fraud?

Depending on the size of the false claim and the state where it was filed, people who commit insurance fraud can spend anywhere from a few months to a few decades in jail. People who commit insurance fraud may also have to pay thousands of dollars in fines. These consequences keep the insurance companies from losing money and also help other customers, whose premiums could go up because of fraud.