Insurance Investigators Best Practice A Claims Manager’s Perspective

Insurance InvestigatorsBest Practice

A Claims Manager’s Perspective

AMPG Facts & Figures

• National claims operation centralised in Wellington

• Part of the Vero stable of brands– Vero– AA insurance– SIS– Comprehensive Travel– Autosure

My Background• NZ Police 24 years, 20 years CIB• Joined AMP General Insurance 1992• NZ Investigations Manager

– Developed external investigator panels– Developed service level agreements & best

practice guidelines– Managed appointments & investigations– Formalised staff fraud training

• NZ Claims Manager from 1998

Investigation Referrals

Claims Strike Rate

Motor 115 30.4%

Home 194 16.7%

Commercial 63 16.5%

372 21.2%

The Investigator

• Experienced criminal investigators

• Transition to competent insurance investigator

• Focus changes

• From thief catcher to information gatherer

• From interrogator to professional service provider

Best Practice• Professional with integrity• Compliance with all legislation• A planned & structured approach• Keep all parties informed regularly • Reporting at earliest opportunity• Concise reporting based on fact• Genuine losses identified early• Comprehensive signed statements• All relevant information gathered & evidential

value preserved

Investigator’s Role• Collect & report all relevant information

– Circumstances surrounding loss– Non-disclosure issues including convictions– Identify any contractual issues– Identify any false statements made– Gather all evidence if claim is false, inflated or

not covered by policy– Report on all matters of concern identified by

claims handler– Identify potential recovery opportunities

Insured Interview• Seek detailed explanations

• Don’t cross examine at 1st interview

• Commit detailed explanations to typed & signed statements

• Seek appropriate proofs / corroboration

• Obtain relevant authorities to access information if required

• Remember the ‘golden rules’

Statements• Signed statement is foundation of any

investigation

• Preference for typed & signed statements

• If handwritten – provide typed transcript

• Essential components include:– Warning to tell truth– Endorsement in subjects handwriting– Signature & initials

Custody of Statements• Original signed statements should be held

by Investigator

• Provide copy only to claims staff

• Original copies required if referred to Police

• Investigator’s role to prepare file for Police consideration if considered fraudulent

• If referred to Police, source all other original documentation from claims staff

Warning• ISO requires claimant to be fully informed

of the risk of supplying false information

• Warning endorsement:“I have been advised that if I supply any

incorrect, untrue or false information & know that it is not correct or true, my insurer has the right to refuse the claim.”

Follow Up Enquiries

• Essential that enquiries are made in most cases to determine whether or not claimant has provided factual information

• Any inconsistency means the claim could possibly be declined

• All avenues should be explored

Depth & Quality of Investigation

• Satisfied loss is genuine:– Initial enquiries may satisfy areas of concern– If so, further enquiries should not be made

without referral / discussion with claims handler

– Provide brief report so claim can be quickly accepted & settled

Avenues to Consider• Proof of purchase enquiries• Cell phone records• Eftpos transactions / bank accounts• Security cameras• Criminal / Traffic convictions• Police / crash reports• Proposal / renewal non-disclosure issues• Witnesses• Advertising property for sale

Pet Hates• Receiving a report outlining circumstances of

loss

• Based entirely on claimant’s version of events

• Several basic follow up enquiries are obvious, but not considered or completed

• The need to refer back to complete enquiries

• Causes further delays / customer frustration

False Statements

• Must show that:– Made deliberately with intent to deceive or

mislead– Material to the claim subject matter– Not an innocent mistake– Would have impact on insurers mind when

considering the claim– Based on fact & not suspicion

Reporting• We don’t need an encyclopedia• Concisely report all the relevant facts• Covering report (2 – 4 pages):

– Executive summary– Key issues / findings– Clear roadmap to attachments which support

findings– Clearly tabulated and readable attachments– Photographs if applicable

Common Traps• Your reports are mostly discoverable

• Compile reports on basis that the claimant, Adviser, Broker, ISO & the courts will read it & scrutinise it

• If your commentary does not assist the claims process, do not include it

• Discuss those issues with claim handler or their supervisor

Investigation Costs• Expectation that fee structure has been agreed

prior to appointment

• Rates have been adhered to

• If investigation timeframe is likely to exceed initial estimates, consult & agree likely on-going costs

• Do not embark on extensive enquiries without consultation & agreement