Claims Representative Duties

by Aurelio Locsin, Demand Media

Owners of insurance policies who file claims for damage or compensation come into contact with claims representatives, who act as intermediaries between customers and insurance companies. These employees have hours that vary from a standard 40-hour week to schedules that include evenings and weekends with clients. Their duties are equally varied and depend on job title.

Claims representatives settle insurance claims by evaluating the facts of a customer situation surrounding the claim, determining whether the loss is covered and what the compensation should be. Thorough investigations are needed to ensure that claims are not fraudulent. As part of their examination, reps may contact the customers’ doctors or employers for additional information if they discover that the filings are questionable. In such cases, these reps may consult legal counsel to determine the best course of action. Eventually, they negotiate settlements and authorize payments, while keeping records of all actions for the customer’s file.

Adjusters are representatives who look at the actual damage to property, such as a car or house, to determine how much their insurance companies should pay. They interview the customer and witnesses and consult with professionals who have expertise on the claim particulars, such as engineers, architects, constructions workers or doctors. Adjusters record findings in written reports, or audio and video media. They also negotiate payment with the client.

Before losses can be covered, the objective monetary value of the covered property must be determined, which is the primary duty of appraisers. Aside from insurance companies, many of these workers are employed by auto damage appraisers. They inspect property damage to estimate the cost of repairs, and then send their information to adjusters, who include the amount in any settlement negotiations.

Claims examiners ensure that claimants and adjusters have followed standard procedures by reviewing submitted claims. Most work for health insurance companies to evaluate whether costs are in line with industry standards for a particular medical condition. They may then authorize payment, deny the claim or ask investigators to investigate further. Those who work for life insurance companies investigate accidents thoroughly due to the extra payments that companies pay for accidental death. They also ensure that new applicants do not have any conditions, such as serious illnesses, that would bar them from receiving coverage.

Insurance investigators step in when the company suspects that claims may not be what they appear to be, or that criminal activity is involved, such as with staged accidents or arson. Much of their work involves surveillance. For example, they may watch individuals who claim back injury to see if they actually do perform vigorous physical activity. They may record their observations on video for use in court cases.

The Bureau of Labor Statistics states that as of May 2011, claims adjusters, examiners and investigators averaged $61,110 per year, or $29.38 per hour. Insurance appraisers of car damage made a mean $59,080 annually, or $28.41 per hour. The BLS also predicts growth rates from 2010 to 2020 will be 3 percent for nearly all claims representatives, but with a decline of 8 percent for insurance appraisers of automobile damage. This is much lower in comparison to a 14 percent increase for all occupations in all industries.

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