What should an adjuster do first if they encounter a claim with suspected fraud?

When an adjuster encounters a claim that raises suspicion of fraud, the most appropriate initial action is to investigate further before making any determinations regarding the claim's validity. Conducting a thorough investigation allows the adjuster to gather all relevant facts and evidence related to the claim. This may include reviewing documentation, interviewing involved parties, and consulting with experts if necessary.

By conducting further investigation, the adjuster ensures they are not jumping to conclusions based on incomplete information, which could lead to an unjust denial or mishandling of the claim. It is crucial for adjusters to approach such situations with a mindset focused on due diligence, following established protocols for fraud detection and reporting.

Taking hasty actions, such as immediately informing the claimant of the suspicion, could jeopardize the investigation, as it may alert the claimant and provide them an opportunity to manipulate evidence or fabricate information. Likewise, denying the claim outright without proper investigation fails to uphold professional standards and could undermine the integrity of the claims process. Reporting to law enforcement is also premature until sufficient evidence is gathered that substantiates the concern for fraud. Therefore, initiating a detailed and careful investigation is the most responsible approach for an adjuster faced with this situation.