Summary
Claims adjusters, appraisers, examiners, and investigators evaluate insurance claims.
What they do
Claims adjusters decide whether an insurance company must pay a claim and if so, how much.
They appraisers, examiners, and investigators typically do the following:
- Investigate, evaluate, and settle insurance claims
- Determine whether the insurance policy covers the loss claimed
- Decide the appropriate amount the insurance company should pay
- Ensure that claims are not fraudulent
- Contact claimants’ doctors or employers to get additional information on questionable claims
- Confer with legal counsel on claims when needed
- Negotiate settlements
- Authorize payments
Claims adjusters, appraisers, examiners, and investigators have varying duties, depending on the type of insurance company they work for. They must know a lot about what their company insures. For example, workers in property and casualty insurance must know housing and construction costs in order to properly evaluate damage from floods or fires. Workers in health insurance must be able to determine which types of treatments are medically necessary and which are questionable.
Adjusters inspect property damage or personal injury claims to determine how much the insurance company should pay for the loss. They might inspect a home, a business, or an automobile.
Adjusters interview the claimant and witnesses, inspect the property, and do additional research, such as look at police reports. They may consult with other workers, such as accountants, architects, construction workers, engineers, lawyers, and physicians, who can offer a more expert evaluation of a claim.
Adjusters gather information—including photographs and statements, either written or recorded on audio or video—and put together a report for claims examiners to evaluate. When the examiner approves the claim, the adjuster negotiates with the policyholder and settles the claim.
If the claimant contests the outcome of the claim or the settlement, adjusters work with attorneys and expert witnesses to defend the insurer’s position.
Some claims adjusters work as public adjusters. Often, they are hired by claimants who prefer not to rely on the insurance company’s adjuster. The goal of adjusters working for insurance companies is to save as much money for the company as possible. The goal of a public adjuster working for a claimant is to get the highest possible amount paid to the claimant. They are paid a percentage of the settled claim.
Appraisers estimate the cost or value of an insured item. Most appraisers who work for insurance companies and independent adjusting firms are auto damage appraisers. They inspect damaged vehicles after an accident and estimate the cost of repairs. This information then goes to the adjuster, who puts the estimated cost of repairs into the settlement.
Claims examiners review claims after they are submitted to ensure claimants and adjusters followed proper guidelines. They may assist adjusters with complicated claims or when, for example, a natural disaster occurs and the volume of claims increases.
Examiners who work for health insurance companies review health-related claims to see whether the costs are reasonable, given the diagnosis. After they review the claim, they authorize appropriate payment, deny the claim, or refer the claim to an investigator.
Examiners who work for life insurance companies review the causes of death and pay particular attention to accidents, because most life insurance companies pay additional benefits if a death is accidental. Examiners also may review new applications for life insurance policies to make sure that the applicants have no serious illnesses that would make them a high risk to insure.
Insurance investigators handle claims in which the company suspects fraudulent or criminal activity such as arson, staged accidents, or unnecessary medical treatments. The severity of insurance fraud cases varies, from overstated claims of damage to vehicles to complicated fraud rings. Investigators often do surveillance work. For example, in the case of a fraudulent workers’ compensation claim, an investigator may covertly watch the claimant to see if he or she does anything that would be suspicious based on injuries stated in the claim.
Work Environment
Claims adjusters and examiners spend time in offices reviewing documents and conducting research. They work outside when examining damaged property. Appraisers and investigators work outside more often, inspecting damaged buildings and automobiles and conducting surveillance. Auto damage appraisers spend much of their time at automotive body shops estimating vehicle damage costs.
Workers who inspect damaged buildings must be wary of potential hazards, such as collapsed roofs and floors, as well as weakened structures.
How to become a Claims Adjuster, Appraiser, Examiner, and/or Investigator
A high school diploma or equivalent is typically required for a person to work as an entry-level claims adjuster, examiner, or investigator, although some positions may require a bachelor’s degree or insurance-related work experience. Auto damage appraisers typically have either a postsecondary nondegree award or previous work experience in identifying and estimating the cost of automotive repair.
A high school diploma or equivalent is typically required for a person to work as an entry-level claims adjuster or examiner. However, employers sometimes prefer to hire applicants who have a bachelor’s degree or some insurance-related work experience.
For investigator jobs, a high school diploma or equivalent is the typical education requirement. Some insurance companies prefer to hire people trained as law enforcement officers or private investigators, because these workers have good interviewing and interrogation skills.
Auto damage appraisers typically have either a postsecondary nondegree award or experience working in an auto repair shop, identifying and estimating the cost of automotive repair. Many vocational schools and some community colleges offer programs in auto body repair and teach students how to estimate the cost of repairing damaged vehicles.
At the beginning of their careers, claims adjusters, examiners, and investigators work on small claims under the supervision of an experienced worker. As they learn more about claims investigation and settlement, they are assigned larger, more complex claims.
Auto damage appraisers typically get on-the-job training, which may last several months. This training usually involves working under the supervision of a more experienced appraiser while estimating damage costs, until the employer decides that the trainee is ready to do estimates on his or her own.
Licensing requirements for claims adjusters, appraisers, examiners, and investigators vary by state.
Pay
The median annual wage for claims adjusters, examiners, and investigators was $66,790 in May 2019. The median wage is the wage at which half the workers in an occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $41,100, and the highest 10 percent earned more than $100,400.
Job Outlook
Overall employment of claims adjusters, appraisers, examiners, and investigators is projected to decline 6 percent from 2019 to 2029.
Technology is expected to automate some of the tasks currently performed by these workers. For example, computer software can evaluate photographs of damaged property and calculate an estimated claim amount. In addition, data collection and processing speed will increase, which will improve efficiency and make workers more productive. Demand for these workers should stem primarily from the growth of the health insurance industry.
Similar Job Titles
Claims Adjuster, Claims Analyst, Claims Examiner, Claims Manager, Claims Representative, Claims Specialist, Claims Supervisor, Corporate Claims Examiner, Customer Care Specialist, Home Office Claim Specialist, Adjuster, Claim Representative, General Adjuster, Insurance Adjuster, Litigation Claim Representative
Related Occupations
Assessor; Tax Examiner and Collector; Revenue Agent; Procurement Clerk; Brokerage Clerk; Equal Opportunity Representative and Officer; Insurance Underwriter; Fraud Examiner, Investigator and Analyst
More Information
The trade associations listed below represent organizations made up of people (members) who work and promote advancement in the field. Members are very interested in telling others about their work and about careers in those areas. As well, trade associations provide opportunities for organizational networking and learning more about the field’s trends and directions.
- American Insurance Association
- National Society of Professional Insurance Investigators
- Society of Claim Law Associates
- The Institutes
- Workers' Compensation Claims Professionals
- International Claim Association
- Loss Executives Association
- National Association of Independent Insurance Adjusters
- Society of Chartered Property and Casualty Underwriters
- Society of Registered Professional Adjusters
Magazines and Publications
Video Transcript
When natural disaster strikes, or a car accident happens, insurance professionals are called in to help start putting the pieces back together. When people have an insurance policy for their health, home, or car, and they become injured or their property is damaged, they make a request —called a claim— for payment to cover their costs. Claims adjusters, appraisers, examiners, and investigators evaluate insurance claims, to decide whether an insurance company must pay a claim, and if so, how much. Appraisers estimate the cost or value of an insured item. Most are auto damage appraisers— they inspect damaged vehicles and estimate the cost of repairs. Adjusters inspect damaged real estate properties and automobiles to determine how much the insurance company should pay for the loss. They gather evidence and report it to examiners. Adjusters negotiate with the policyholder to arrive at a final payment amount for their claim. Claims examiners review claims to ensure guidelines are followed properly. They review health-related claims to determine whether to pay… deny… or refer a claim to an investigator. Insurance investigators handle potentially fraudulent claims or suspected criminal activity such as arson, staged accidents, or unnecessary medical treatments. Claims adjusters, examiners, and investigators spend time in the office, and out in the field to inspect damaged properties. Auto damage appraisers spend much of their time at automotive body shops to estimate repair costs. Entry-level claims adjusters, examiners, and investigators need a high school diploma or equivalent. Auto damage appraisers require either a certificate in the field, or work experience estimating the cost of car repairs.
Content retrieved from: US Bureau of Labor Statistics-OOH www.bls.gov/ooh,
CareerOneStop www.careeronestop.org, O*Net Online www.onetonline.org