Insurance Fraud Investigation: A Beginner-friendly Guide

Insurance Fraud Investigation: A Beginner-friendly Guide

BY SIFS India | January 13, 2022

Insurance Fraud Investigation: A Beginner-friendly Guide

Insurance is done to protect policyholders against risks. But several times, both policy issuers and holders indulge in unethical activity to commit insurance fraud to make more money out of greed.

Here the need for insurance fraud investigation arises. Companies nowadays act with caution, and they might appoint an insurance fraud investigator to check whether the claim made is genuine or not.

Also, while applying for claims, individuals need professional help to ensure fast claim settlement. 

Insurance fraud has existed since insurance was commercialized. Several types of insurance frauds occur in every sector affecting the lives of both innocent people and policy issuing companies. 

What is Insurance Fraud?

Insurance fraud can be defined as an illegal activity done either by the issuer or buyer of the policy.

A seller can perform fraud by selling fake policies or providing misleading information to the buyer to make more commissions.

The buyers can indulge in fraudulent activity by making false claims to get the money they do not deserve.

However, most insurance fraud cases occur from the side of policyholders than policy issuers.

Insurance Fraud Categories

Soft Fraud

Soft fraud, also known as opportunistic, is unplanned and the most common insurance fraud. In this policyholder makes a legitimate claim exaggeratedly.

For example, if your car met with an accident and you portray injuries exaggeratedly, to get more compensation from the insurance company.

Hard Fraud

Hard fraud is a planned fraud where you plan or take someone’s help to claim money for the damages from an insurance company. 

For example: deliberately getting into an accident so that another person has no clue to prevent that collision. Another example could be faking your death to claim life insurance death benefit.

Most Common Types of Insurance Frauds Investigations

Health Insurance: This investigation is done to determine if someone is receiving health care benefits they do not require, filing invalid claims, or filing a claim against someone else’s insurance. The investigators analyse billing records to check whether doctors and patients commit fraud.

Home Insurance: This type of investigation covers analyzing false damage claims due to disaster. Investigators check what is included in the coverage right before filing and also verify the authenticity of the property damage claims.

Life Insurance: This investigation type involves analyzing cases where people claim excessive life insurance or while still alive. Investigators check the person's existence in the name of whom the insurance claim is being made.

Car Insurance: This type of investigation is required when people make false vehicle theft claims or purposely collide with other vehicles, making the other driver faulty to file a claim and get money. 

Workers Compensation Insurance: This investigation is carried out to analyze the seriousness of the injury and whether it occurred while the concerned person was working.

Insurance Company Fraud: In this insurance company takes the investor's money but does not follow the compensation norms. The investigator helps the victim during the court case.

How to Become Insurance Fraud Investigator?

Insurance fraud is a widespread problem, and its cost is increasing day by day. It has led to a major surge in demand for insurance fraud investigation specialists. But becoming an insurance fraud investigator requires you to fulfill certain conditions. However, if you have an interest, you start at any point in your life.

If you are pursuing a course or degree in criminal justice, finance, business administration, or risk management, getting certified as an insurance fraud investigator will open the door to more job opportunities.

You can enroll in a certificate, diploma, degree, or short-term training program to understand the working of the insurance industry, how to handle financial risks, and investigate claims. The duration of the training can vary from a few weeks to several months, depending on your expertise level.

How Does Insurance Fraud Investigation Work?

Several insurance fraud investigation methods are available to find whether the claims made are real or fake. As an insurance investigator, your primary goal is to collect evidence to analyze the authenticity of the insurance claim made by the policyholder by reviewing related documents. 

Insurance investigation agency or individual investigator is mainly called upon by the insurance companies or businesses when they suspect fraud in a suspicious insurance claim.

Insurance investigators may:

- Consult with law enforcement experts

- Carry out surveillance

- Perform history or background check of the claimant

- Do medical billing records analysis

- Perform insurance cover analysis

After completing the investigation process, a report containing all the findings is prepared and forwarded to the concerned authorities. They then might take the help of law enforcement professionals to seek criminal or civil charges. In the court hearing, insurance investigators might be called upon to testify their findings.

Final Words

The number of insurance policyholders and the fraud rate has increased with time. The demand for trained insurance fraud investigators who can carry out unbiased and accurate insurance fraud investigations has expanded to combat these frauds. 

However, across the globe, the demand is much more than supply. There is a need for professional agencies and trained individuals who can independently carry out such investigations and help speed up justice.


Sherlock Institute of Forensic Sciences, India - Forensic Science lab & Training Institute

SIFS India, a Govt. of India registered, ISO 9001:2015 & 10002:2014 certified, is a notable Private Forensic Science Laboratory and Training Institute providing robust Criminal Investigation and Insurance Fraud detection services for several years.

Along with providing investigating services, they are on a mission to serve humanity by creating a stream of trained forensic experts.

If you wish to get associated with the nation’s best Forensic Training Institution and boost your career, in that case, you can check out several certificates, diplomas, PG diplomas, workshops, and internship opportunities offered by them both offline and online mode.

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