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Insurance Claims: Importance of Claim Investigation

Claim Diaries-2

As a general insurance company, there are a number of times when we come across a number of seemingly fraudulent claims. Spotting fraudulent claims and separating it from genuine ones can be an uphill task for the insurer. However, as a company dedicated to customer service we know the importance of spotting the legitimate claims. Here is a case study that provides an excellent example of how a claim which seemed fraudulent on the surface turned out to be a genuine one after careful investigation of the claim.


There was a case registered at the Siliguri Branch, wherein the insured had met with an accident on the same day of the issuance of the policy, i.e. on 8th august 2014. The claim was assigned to us for investigation.

The policy was issued on 8th August at 7:21 pm in the evening and during investigation of the case we found that the person had met with an accident on 5 pm the same day. The claim could have been denied based on the fact that the accident had happened before the issuance of the policy. However, I suspected some foul play and decided to investigate the case further.

What We Did

To ensure that everything was in order, I went to Siliguri from Delhi to investigate the case personally. There I met the accountant who gave me the collection register of the branch. The register clearly mentioned that the payment of insured was submitted on 6th August 2014 but somehow the policy could not get issued on 6th and 7th due to some technical issues.

I also checked the agent float there also it was found that the IMD had submitted Rs.3000 against PA (Personal Accident) policies for 9 other people. The payment was done against the same receipt number.

I also met the agent who further gave me a written statement that he had submitted the payment on 6th August for 10 people so that their PA policies could be issued.

What Was the Outcome

I then concluded that the IMD and the insured were not at fault. I came back and submitted my report to claims team, shared the findings with them and then requested the claims manager to process the claim. Finally the claim was settled. I was satisfied that the claim got settled and we were able to settle genuine claim.

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This claim story was shared by Dr Jagroop Singh Khokhar, Senior Executive Fraud Prevention Investigation, FPLM-Health, Bajaj Allianz General Insurance Co. Ltd.

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Published on:17 Dec, 2014

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