​In the world of claims investigation, making a quality referral to an investigative vendor can directly impact the outcome of a case. A well-planned referral not only improves efficiency, but also helps ensure accurate, timely results. Below is a practical guide to help claims professionals make effective vendor referrals, improve investigative outcomes, and build stronger partnerships.

Special Investigation Units (SIU) play a critical role in life and disability insurance claims. Their purpose is not simply to investigate fraud, but to help ensure claims are handled thoroughly, fairly, and consistently.

​By Marlon Fearon

The views expressed in this article are those of the author in his capacity as a member of the ICA Fraud Committee and do not necessarily reflect the views of Swiss Re or its affiliated entities.
​
Life and health insurance exist to provide financial protection during some of the most vulnerable moments in a person’s life—illness, injury, disability, or death. Unfortunately, those same features that make these products essential also make them highly attractive targets for fraud. Across the insurance industry, life and health lines consistently experience significant fraud exposure due to a unique mix of emotional, financial, and structural factors.

By Margo Jenkins (AAA Life) & Rob Strange (Evadata)
​
The landscape of insurance fraud is rapidly evolving, and life insurance claims are no exception. With the accelerated development and accessibility of Artificial Intelligence (AI) and generative AI tools, claims examiners are facing sophisticated new threats. Understanding these emerging risks and adopting proactive AI-powered defenses are crucial to safeguarding your company’s financial health and maintaining trust with legitimate policyholders.

​Case Managers need to be aware of the warning signs called “red flags” that indicate a claim may be fraudulent. Such signs may indicate the need for closer scrutiny and further investigation during the claims handling process. The existence of more than one fraud indicator does not necessarily mean that a claim is fraudulent. Indicators of fraud may exist purely through coincidence in legitimate claims. Claims that raise concerns need to be examined carefully before final conclusions are drawn.