Claim Investigation, Damage Assessment, and Fraud Detection
This domain tests method: how you gather evidence, establish cause, verify quantum and recognise indicators of fraud without overstepping into accusation.
Investigation
- Inspect promptly, before repair or disposal, and secure the scene: photographs, sketches, samples, CCTV, witness details.
- Obtain independent evidence: fire brigade or forensic report, meteorological records, police report, purchase invoices, stock records, bank statements, maintenance logs.
- Interview the insured and witnesses separately; record statements in writing and have them signed.
- Establish cause and origin before discussing quantum; keep chain of custody for samples.
Quantum
Verify ownership, existence, value and loss for each item; reconcile the declared stock against purchases, sales and tax filings; test the sum insured for adequacy and flag underinsurance.
Fraud indicators
- Policy taken out shortly before the loss; premium in arrears.
- Claimed values inconsistent with accounting or tax records; records "conveniently" destroyed.
- Forced entry inconsistent with the loss; arson indicators or prior fire history.
- Late notification, pressure for fast payment, threats to involve the media, refusal of access.
- Same repairer or medical provider recurring across claims.
Worked example
A fire destroys stock claimed at 900m. Purchase invoices support 400m and tax filings report 350m of stock. Reasoning: not proof of fraud, but material inconsistency; the adjuster requests the accounting system backup and refers the file internally before quantifying, and never states an accusation to the insured.
Traps that cost marks
- Accusing the insured of fraud in writing without evidence.
- Relying solely on the insured's own inventory list.
- Letting repairs destroy the evidence before inspection.
- Ignoring that a lower figure may simply reflect underinsurance.