How to Answer: How do you approach a claim that seems suspicious or potentially fraudulent?
Advice and answer examples written specifically for a Claims Adjuster job interview.
13. How do you approach a claim that seems suspicious or potentially fraudulent?
Why the Interviewer Asks This Question
According to a March 2023 study, between 10% and 20% of insurance claims are fraudulent. The interviewer asks this question to determine your process when you have a suspicious claim. When encountering a suspicious or potentially fraudulent claim, it is essential to approach it with caution and conduct a thorough investigation. Start by gathering all relevant information about the claim and the claimant, including any documentation or evidence provided. Look for any inconsistencies or red flags that may indicate fraud. Conduct interviews with the claimant and any witnesses to gather additional information and consult with experts in a particular field if necessary. Throughout the investigation, maintain open communication with the claimant andinform themd of any updates or findings. If evidence of fraud is discovered, report it to the appropriate authorities and take steps to prevent further fraudulent activity. The key is to remain objective, gather as much information as possible, and ensure a fair and accurate resolution. Describe your approach to these situations.
Written by Krista Wenz on June 16th, 2023
Entry Level Example
"As a new claims adjuster, I would approach a suspicious or potentially fraudulent claim with caution and a thorough investigation. I would gather all necessary information about the claim, including the incident report, medical records, and other relevant documents. I would also interview witnesses and any parties involved in the claim.
If the evidence suggests the claim may be fraudulent, I would escalate the claim to a senior claims adjuster or special investigations unit for further review. I would also work closely with law enforcement and other relevant authorities to identify and address any potentially fraudulent activity.
As a claims adjuster, I understand it is essential to remain impartial and objective in all cases and to always prioritize the best interests of the policyholder and insurance companies best interests. By conducting a thorough investigation and following proper procedures, I can help ensure that all claims are handled fairly and accurately while protecting against potential fraud."
Written by Krista Wenz on June 16th, 2023
Answer Example
"When I have a claim that raises suspicion, I always keep an open mind and do not jump to conclusions. I understand that sometimes what may seem suspicious at first glance may have a reasonable explanation. However, if I still have concerns about the legitimacy of the claim after my investigation, I will escalate it to the appropriate authorities for further review. Ultimately, I aim to ensure all claims are handled fairly and accurately while protecting the company from any potential fraud."
Written by Krista Wenz on June 16th, 2023
Experienced Example
"When it comes to handling suspicious claims, I keep a few key things in mind. First and foremost, I always approach each claim with an open mind and a willingness to investigate thoroughly. This means gathering as much evidence and information as possible and never making assumptions or jumping to conclusions.
Another important factor is communication. I make sure to keep the claimant informed throughout the process, explaining my findings and the reasoning behind any decisions made. This helps to build trust and transparency and can often diffuse any potential suspicion or hostility.
Of course, there are also certain red flags that I look out for when assessing a claim. These can include inconsistencies in the story, lack of documentation or evidence, or a history of previous claims. If something seems off, I will always dig deeper to get to the bottom of it.
Ultimately, my goal is to ensure that each claim is handled fairly and impartially while protecting the interests of the insurance company and its policyholders. By staying vigilant and following a thorough investigative process, I am able to achieve this goal and maintain the trust and confidence of all parties involved."
Written by Krista Wenz on June 16th, 2023