Insurance Claims, Fraud

Adjuster
An adjuster who works as an independent contractor, hiring himself out to insurance companies or other organizations for the investigation and settlement of insurance claims. Independent adjusters represent the interests of insurance companies. Contrast with Public Adjuster.

Claims
A representative policy definition of Claims is a demand for money upon the insured, including service of suit, or institution of arbitration proceedings against any insured. However, depending on the policy the "Demand" may be defined as written or verbal or may simply be the insurers knowledge of an incident or circumstance that may lead to a claim. In the latter case insurers may be reluctant to report an incident to their carrier fearing a increase in premium or a non-renewal of their policy.

Claims Made Policy
The claims made policy is the vehicle by which nearly all professional liability insurance is made available. Coverage must be in force not only when the claim is made but also when the alleged act, error or omission that results in a claim occurred, or there is no coverage.

Insurance Claim
A claim for reimbursement from the insurance company when the insured has suffered aloss that iscovered under aninsurance policy.

Fraud
Dishonest act by policy holders to obtain payment of insurance claims that would otherwise not be covered by insurance. It also could involve lying or misrepresentation by an insurance company or its officials.

Individual Fraud
A type of medical insurance fraud committed by individuals on their medical expense claims in order to obtain benefits in excess of their medical expenses. Contrast with provider fraud.