Insurance Claim Investigation
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Transcript of Insurance Claim Investigation
Incident Incident Investigation &Investigation &
Getting Accurate Getting Accurate Recorded Recorded
StatementsStatements
Why is it important to promptly do a Why is it important to promptly do a professional investigation & statements?professional investigation & statements?
• Get the facts while they are fresh!
• People’s recollections degrade over time.
• People come and go.
• Prevents witness accounts from changing later…
• Provides a timely, visible, credible response to questionable claims.• A company’s reputation for resisting fraud is built over time.
• Deters potential future fraudsters
•Employers
need to look
out for
Themselves!
When you get a reputation forpaying everyone that comes to your door…….
When you get a reputation forpaying everyone that comes to your door…….
You soon have a lot of peoplecoming to your door!
Effective investigation may Effective investigation may
•Mitigate questionable claims
•Defeat fraudulent claims
•Assist in preventing future accidents
A good investigation is:A good investigation is:
•Focused/Relevant
•Thorough
•Objective
•Professionally conducted
•Professionally organized
•Professionally documented
Skilled Interviewing is an Art & Science:Skilled Interviewing is an Art & Science:
•Reluctant/hostile witnesses
•Deceptive witnesses
•Witnesses with hidden agendas
•Poorly-educated witnesses
•Disinterested witnesses
•Language barriers
Skilled Interviewers should:Skilled Interviewers should:
•Know relevant worker’s compensation issues
•Be armed with the facts
•Be prepared for the interviews
•Have good people skills
•Have good communication skills– Ask the right questions
– Listen to the answers
– Keep asking relevant questions until question is answered
•Be able to analyze, summarize and document results
Logic PathLogic Path
• What do I know about this incident?
• What do I suspect?
• What issues am I trying to resolve?
• What information would help me resolve those issues?
• Where can I get that information?
The finished product should be:The finished product should be:
• Professionally done
• Objective
• In-depth
• Accurate
• Relevant
• Well-organized
• Well-written
The net result of a good investigation:The net result of a good investigation:
• Accurate and thorough documentation of the incident.
• Permanent record of the facts.
• Basis for action by employer, L&I
• Learning tool for Safety improvement.
The bottom line….The bottom line….
• L&I can only act on the information presented to it.
• The worker’s side of the claim will be documented by professionals :
•Doctors
•Attorneys
• The employer’s side of the claim also needs to be professionally documented!
Good Investigations Save Money!Good Investigations Save Money!