Insurance Claims
Insurance claims: who does what and when does a lawyer get involved?
There are many types of insurance such as auto, home, health and life insurance. In all of these areas, individuals purchase insurance to protect themselves against the "what ifs" in life. What if I get in a car accident? What if a hurricane blows a tree through the roof of my house? What if I have to be hospitalized? Insurance is designed to make sure that those types of situations don't break you financially. Insurance premiums are devised to allocate the risks of a loss from the individual to a great number of people. In other words, each individual gets the opportunity to pay a 'premium' to join the insurance pool, from which any losses are paid out.
Individuals and businesses purchase insurance policies to protect against monetary losses. In the event of a loss, policyholders submit insurance claims and request payment as compensation for their loss. Once an insurance claim is received, the adjusters, examiners and investigators who work for the property and casualty insurance companies then go to work.
Adjusters investigate insurance claims, negotiate settlements and authorize payments. Adjusters may also consult with other professionals, such as accountants, architects, construction workers, engineers, lawyers and physicians, who can offer an expert evaluation in regards to the insurance claim. When an adjuster finds that an insurance claim is legitimate, he/she then negotiates with the claimant and settles the claim. When claims are disputed, adjusters will work with lawyers and expert witnesses to defend the insurer's position.
Claimants may choose not to rely on their insurance company's adjuster and instead hire a public adjuster. Public adjusters help clients prepare claims to insurance companies and work towards negotiating a fair settlement. They perform the same services as adjusters who work directly for companies, but they're working in the best interests of the client, rather than the insurance company.
The examiner's job is similar to an adjuster's. Examiners review insurance claims and ensure that proper guidelines have been followed. Most claims examiners work for life or health insurance companies. In health insurance companies, examiners review health-related claims to assess whether costs are reasonable based on the diagnosis. The examiners are given guidelines on the average period of disability, expected treatments, and the average hospital stay for patients with the various ailments for which an insurance claim may be submitted. Examiners interview medical specialists and verify the information reported in the insurance claim. Examiners will then either authorize the appropriate payment or refer the claim to an investigator for a more thorough review. Examiners also handle new applications for life insurance by making sure that applicants have no serious illnesses that would make them a high risk to insure and therefore disqualify them from eligible for medical or life insurance.
A claims investigator deals with the insurance claims where there is a question of liability or if fraud or criminal activity is suspected such as arson, false workers' disability claims, staged accidents or unnecessary medical treatments. They must determine whether the customer's insurance policy covers the loss and how much of the loss should be paid to the claimant. Investigators may visit claimants and witnesses to obtain a recorded statement, take photographs and inspect facilities.
Amidst all their prying for pertinent information, investigators must be mindful not to violate the claimant's rights under Federal and State privacy laws. Investigators often consult with a lawyer and can be expert witnesses in court cases. Lawyers are usually called upon for insurance claims and court cases involving personal injury. Personal injury includes car accidents, medical malpractice, worker's compensation, product liability, wrongful death - - even animal bites! Lawyers who specialize in personal injury are well-versed in this type of law and can explain all the options and guide you through the process of receiving monetary compensation.
Be aware that insurance companies vary in their timeliness of taking care of your insurance claim. So don't wait to report the incident to your insurance provider, your employer and a lawyer. It's to your benefit to record as many details of the accident/injury as possible. Take pictures and statements from witnesses immediately after the incident to make sure your lawyer and insurance company has enough information to work with. Not reporting an accident immediately can damage your chances to a fair compensation.
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