The Role of the Claims Investigator

People inside and outside the insurance business can sometimes be confused about the role of the claims Investigator. I think that makes it an appropriate subject for our first posting. The Claims Investigator has become the “go to” person when a claim is notified. They may be an in-house appointment or may be hired on a contract basis for individual claims.

When understanding the role it helps to know where it came from. It has grown from that of a Claims Inspector who typically worked with an Insurance Company. There are many aspects to that Claims Inspector role. At one time it was common for them to be the main manager of individual motor and liability claims. They would go to the policy holder’s premises, meet with and contact witnesses, make relevant enquiries and decide on policy cover issues with the underwriters. They might have been the person to put an estimate or reserve on the claim and they would often be the one to attend at court when the case was in for hearing or settlement meetings.

Most Investigators have a professional qualification but as well as this they have significant “on the job” training. Training for this role in the companies involved a period as an “apprentice”. The importance of gathering the right information preferably during the first visit is hard learned. The need to again take to the Irish back roads in winter to get the missing statement or photograph tended to be a stern lesson!

It is perhaps in the court arena that the real experiences that forge an investigator are learned. As the insurance company representative at court the individual often had control over the payment of a large amount of money. The alternative to payment was often an expensive fight in court with the possibility of a poor outcome. A major case will often involve a plethora of experts. It would not be unusual to have two barristers, a solicitor, an engineer, a motor assessor, and a number of doctors depending on the injuries. And that is only our side! As well as this there may be several witnesses all with their own bias and interests. The final decision about what to do in a case often rested with the Insurance Company Representative (Claims Inspector). They would need to take all of the advice offered and consider it in the light of the facts and past experience. Different weights would also be attached to that advice depending on who it is from. It is also sometimes the case that there is a need to fight a case for a social or business reason that is outside the normal legal considerations. This needs to be understood and held in context by the Inspector.

It is very useful if a Claims Investigator has been through all of this. It is then possible to sort the vital information from the remainder at the earliest stages and to see how different pieces of information will be seen by the courts. How will a witness stand up to examination and indeed cross examination? Are there legal obligations that have not been attended to that would hurt any chance to have the case defended. This has come into even sharper relief with the advent of the Injuries Board. Making the wrong decision on a case can attract a very significant penalty in terms of costs. Equally if insurers consent to assessment in haste, their decision will also often be regretted (when a larger than expected award is made) or result in significant client dissatisfaction.

For a relatively modest fee, the claims investigator will use experience and knowledge to identify the issues and important factors in making the right decision. Specifically, in a typical case an Investigator will attempt to:

  • Visit the scene of the accident and take photographs that will help to explain to someone sitting at a desk miles away what may have happened during an accident
  • Take measurements and generally be able to describe the scene in a factory environment for example.
  • Understand and be able to explain the operation of any machinery or processes that are involved in the accident/incident
  • In appropriate cases some Investigators present their findings using audio or video files. DVD Video is of good quality and easy enough to present in court. Smaller JPEG files might be used to do a “walk thorough” of the accident scene to better exlain what happened.
  • Provide details of all relevant parties
  • Meet with any witness and take statementswhere possible
  • Meet with the insured or a senior person in the organisation if possible to get their views
  • Consider whether the circumstances fall within the scope of the policy cover and if there are any issues that need to be addressed
  • Get general details of any injuries suffered and attempt to ascertain the nature of the earliest complaints to see if they are consistent with complaints currently being made
  • Get information about the claimant. The insured is often a source of valuable information. It is also possible that the complaints allegedly arising in the accident are in fact of long standing
  • Consider the allegations made by the other side and use these in an appropriate way during interviews.
  • Consider how any legal cases or statutory requirements might impact on the case. (A good general knowledge of relevant law is required but insurers will usually seek specialist legal advice at a later stage when and if matters progress). This can be very important as the legal framework within which a case will be tried should inform the nature and scope of the investigations.
  • Give a view on the potential areas where the insured may have a liability
  • Consider whether other parties may have responsibility and why.
  • Advise how the insurer/client might proceed. Specifically one might recommend settlement or point out what further action is needed if consideration is to be given to fighting the case.
  • Sometimes an Investigator will become involved later in a case and may be asked to do a specific job such as to interview a specific witness

It will be seen that the Investigator needs a very varied set of skills. These must be allied to a suitable personality and strong presentational skills. Clients vary in their desire for information with some needing chapter and verse with others sighing if they get more than a few bullet points. These and every requirement in between must be accommodated. In recent times there has often been a de-coupling of the investigation and handling functions. It would be common for the investigator to discuss the case with the handler at some stage to help decide on strategy and to explain further any difficult issues. Often more information will have been collected than is presented in the Investigators Report. Sometimes such information only becomes relevant because new allegations are made and it is useful to check back with the investigator to see if they are aware of any relevant facts or if it changes their view.

Because Investigators are usually Qualified with a Professional body they are governed by a Code of Ethics and are expected to conduct themselves in an appropriate way. Dress is usually conservative and quite formal especially during corporate visits. Certain individuals may be easier to approach in a less formal way and this would be a call for the individual investigator.

It is not possible for a Claims Investigator to go into a place of work and question policies regarding safety equipment or processes unless clear attention is paid to these very same issues by the investigator. All safety equipment that might be needed is carried at all times including:

  • Safety Boots
  • Hi-Viz Jacket
  • Overalls
  • Hard Hat
  • Bag and camera bag with strap carry to allow hands free for climbimg
  • Basic Face Mask
  • Ear Protectors

Other more specialist equipment will usually be provided by the host company and this might include:

  • Gas Masks
  • Safety Lanterns
  • Specialised Breathing Apparatus
  • Hygiene controlled outer garments
  • Survival suits for helicopter flight
  • Specialised lamps for use in mines

For a “people person” who also enjoys figuring things out, it is hard to think of a more interesting and fulfilling career. I have been by helicopter to the oil rigs and by boat to near uninhabited islands off the coast of Ireland. I have been several miles underground and I have been inside some of the biggest chemical plants on this island. I regularly get to meet some of the brightest legal and medical minds as well as General Managers, engineers and HR specialists. We could be asked to investigate anything from a broken toe to bullying allegations that are life altering for those concerned. Sometimes an “emergency” response is needed, after a serious industrial or motor accident for example, other times investigation may take place much later. As can be seen in this brief description the role of the Claims Investigator is varied and interesting, often deeply engaging and requiring great flexibility, knowledge and practical experience.

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