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Claims Examiner Job Description

The Claims Examiners reviews claims made against insurance companies. Claims Examiners are sometimes referred to as Reviewers, are employed by life and health insurance companies.

Primary Objectives:

  • The Claims Examiner is responsible for approving or rejecting claims or arranging settlements.

  • Claims Examiners do their work behind the desk not at the scene like claims adjuster.

  • The Claims Examiners does most of their work by telephone and by mail.

One of the first things that the Claims Examiners must do is to verify the facts after a customer files a claim. The Claims Examiner must examine the facts and compare them to the insurance policies to insure that all the information is correct to determine whether the claims are covered under the policies. A policy is a contractual agreement between an insured person or business and an insurance company. Taking this in mind the Claims Examiners usually speaks with the policyholder, insurance agents, and other companies to make a determination about the claim that was just filed.

The Claims Examiner may review medical bills or accident reports, or they may consult specialists. The Claims Examiners must speak to many different people before they can approve or disapprove a claim. For instance the Claims Examiner may need to speak to doctors in case of investigating an accident or they may need to speak to auto mechanics when a vehicle is involved in an accident. The Claims Examiner often needs to speak to people in different professions in order to get their opinion. The Claims Examiner must determine the legacy of the claim but also the extent of the claim. In some cases when it comes to certain things like automobiles, personal property, and other objects it is easy for the Claims Examiners to make a determination. When a person has been injured it is difficult at times to determine the severity of the injury. The Claims Examiner must depend on the doctors and other professionals before they can make such a determination.

Unfortunately, it is human nature to claim that you are seriously injured in order to have a large claim. This is some of the facts that Claim Examiners deal with everyday when it comes to resolving claims that are placed with personal injuries. It can become difficult for a Claims Examiner to make a decision on personal property destruction as well because at times the extent of the damage may not always be visible or it may seem worse than it really is. Claims Examiners review medical bills or accident reports, or they may consult specialists. All these things are highly necessary when it comes to making a decision on a claim.

The claim is carefully reviewed, the settlement is calculated then the Claims Examiner authorizes payment of the specified amount. Most Claims Examiners deal with cases in which the loss is comparatively low. When it comes to large or unusual claims or possible false claims then they get referred to a Senior Claims Examiner. The Senior Claims Examiners has to dig deeper into the situation often interviewing witnesses or professionals who know if the claim is valid. For instance when a person claims to have an injury such as whiplash then the Senior Claims Examiner must interview the physicians who examined that person and get their professional opinions.

When a person claims that some personal property was damaged due to storm then the Senior Claims Examiner must interview neighbors, mechanics when necessary, or builders to make a determination to find out if this really happened because of the storm or if this was a preexisting condition. In some cases a wind storm can do a lot of damage to a home but the home could have had some damage before the storm happened. The roof for instance could need replacing and the owner might use the guise of the windstorm to get the roof fixed. This is just an example and of course not the common type of problem. But Claims Examiners are often faced with problems that are hard to determine and in order to make a determination that is fair to the insurance company and the client a Senior Claims Examiner with a lot of experience takes control of the situation. In this manner a decision usually is determined that is fair to everyone concerned in most cases.

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