Profession insurance fraud investigator

Insurance fraud investigators combat fraudulent activities by investigating the circumstances of certain suspicious claims, activities related to new customers, buying insurance products and premium calculations. Insurance fraud investigators refer potential fraud claims to insurance investigators who then undertake research and investigations to support or deny a claimant's case.

Personality Type

• Conventional / Enterprising
• Conventional / Realistic
• Enterprising / Conventional

Knowledge

• Claims procedures

  The different procedures that are used to formally request a payment for a suffered loss from an insurance company.

• Principles of insurance

  Understand the principles of insurance, including third party liability, stock and facilities.

• Insurance law

  The law and legislation concerning the policies of transferring risks or losses from one party, the insured, to another, the insurer, in exchange for a periodic payment. This includes the regulation of insurance claims and the business of insurance.

• Actuarial science

  The rules of applying mathematical and statistical techniques to determine potential or existing risks in various industries, such as finance or insurance.

• Fraud detection

  The techniques used to identify fraudulous activities.

• Types of insurance

  The various types of risk or loss transfer policies that exist and their characteristics, such as health insurance, car insurance or life insurance.

Skills

• Conduct financial audits

  Evaluate and monitor the financial health, the operations and financial movements expressed in the financial statements of the company. Revise the financial records to ensure stewardship and governability.

• Detect financial crime

  Examine, investigate, and notice possible financial crimes such as money laundering or tax evasion observable in financial reports and accounts of companies.

• Interview insurance claimants

  Interview people who have filed claims with the insurance corporation they are insured with, or through specialised insurance agents or brokers, in order to investigate the claim and the coverage in the insurance policy, as well as detect any fraudulous activities in the claims process.

• Review insurance process

  Analyse all documentation related to a specific insurance case in order to ensure that the application for insurance or the claims process was handled according to guidelines and regulations, that the case will not pose significant risk to the insurer or whether claims assessment was correct, and to assess the further course of action.

• Analyse claim files

  Check the claim from a customer and analyse the value of the lost materials, buildings, turnover or other elements, and judge the responsibilities of the different parties.

• Assess customer credibility

  Communicate with customers to assess whether their true intentions are in line with what they claim in order to eliminate any risks from a potential agreement with the customer.

• Assist police investigations

  Assist in police investigations by providing them with specialised information as a professional involved in the case, or by providing witness accounts, in order to ensure the police have all relevant information for the case.

Optional knowledge and skills

Source: Sisyphus ODB