An insurance investigation is an inquiry conducted by an insurance company to determine whether a claim is justified. Insurance investigators gather information about the circumstances surrounding a claim and determine whether the claimant is eligible for compensation. Investigations may include interviews with the parties involved, document reviews, research into the circumstances of the claim or verification of the loss suffered.
Indeed, to combat insurance fraud, insurance companies and mutual insurers have long been conducting investigations to clear up any doubts.
Why conduct an insurance survey ?
According to the Agence de lutte contre la fraude à l’assurance – ALFA – insurance fraud is:
“An intentional act, carried out by a moral or physical person, in order to unduly obtain a profit from the insurance contract.”
While it is difficult to put a precise figure on insurance fraud, it is generally accepted worldwide that between 5% and 10% of claims made by policyholders are the result of fraud.
There are several ways to combat insurance fraud. Insurance companies can put in place systems for monitoring and detecting fraud, systems for verifying the information provided by policyholders, reward systems for reporting fraud and awareness campaigns to inform policyholders of the consequences of insurance fraud.
Insurance companies can also work closely with the authorities to investigate and prosecute fraudsters.
In order to detect fraud attempts as effectively as possible, insurers are equipped with monitoring and alert tools that are increasingly based on artificial intelligence.
After attempting to clear up any doubts about a fraud attempt, or in order to obtain evidence of the fraud, the insurer can call on the services of a private detective specialized in this field: the insurance investigator, responsible for carrying out insurance investigations necessary to reveal the truth.
An insurance investigation generally takes place in several stages.
Insurance checks and verifications
First, the insurer gathers information about the claim and the circumstances surrounding it. This may include interviews with the parties involved, reviews of documents and evidence, and research into background and other relevant information.
Once the insurer has gathered sufficient information, he can assess the claim and determine whether compensation is due. In case of doubt, an insurance investigator can be appointed to carry out investigations.
The role of the insurance investigator
When an insurance company suspects fraud or abnormality, it mandates an insurance investigator. The investigator then investigates the claim and provides information to the company so that it can make an informed decision.
Compensating the insured following an investigation
The purpose of an insurance investigation is to remove any doubts the insurance company may have as to whether or not compensation should be paid. In the course of the investigation, the detective may come to the conclusion that the policyholder is acting in good faith, removing all doubts.
On the contrary, the investigator may succeed in uncovering the insured’s fraudulent maneuvers and attempted fraud. Sometimes, doubts remain at the end of the investigation, and it’s up to the insurance company or mutual insurer to make a choice.
Either it compensates the insured because the insurance company considers that the contract, the loss and the damage are real, or it considers that there has been an attempt at insurance fraud.
In the latter case, the company will not compensate the insured and may even file a criminal complaint.
Contestation by the insured
If the insurance company refuses to pay compensation, or if the financial proposal does not satisfy the insured, the latter can take legal action with the help of a lawyer to contest the decision.
The legal means used by the insured’s counsel vary. Often, however, when the investigation report is conclusive and serves the policyholder’s interests, the policyholder’s lawyer seeks to remove it from the proceedings on the grounds of invasion of privacy.
This is why, in an insurance investigation, the investigator must conduct his inquiries with care and scrupulous respect for the law.