Best Practices for Claims Investigation: Insights from a Claims Manager

1. Insurance InvestigatorsBest Practice A Claims Manager’s Perspective

2. AMPG Facts & Figures • National claims operation centralised in Wellington • Part of the Vero stable of brands • Vero • AA insurance • SIS • Comprehensive Travel • Autosure

3. 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

4. Investigation Referrals

5. The Investigator • Experienced criminal investigators • Transition to competent insurance investigator • Focus changes • From thief catcher to information gatherer • From interrogator to professional service provider

6. 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

7. 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

8. 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’

9. 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

10. 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

11. 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.”

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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