claims-fraud-investigation.md

Uploaded 8/8/2026, 11:53:01 PM

# Claims Fraud Investigation Escalation

When the Claims Team or an Adjuster suspects fraud, they flag the claim in the Claims Management System, which automatically routes it to the Fraud Investigation Unit instead of continuing through normal adjustment.

The Fraud Investigation Unit first reviews the claim history in the Policy Administration System, then interviews the policyholder, then decides whether to refer the case to the Compliance Officer.

Policy requires any claim over $25,000 with two or more fraud indicators to be automatically referred to the Compliance Officer — this is not adjuster discretion. In practice, the Fraud Investigation Unit often loops in the Compliance Officer earlier than required when a case looks serious, rather than waiting for the formal threshold.

Confirmed fraud cases are referred to outside legal counsel and are exempt from standard claim payment timelines under the Fraud Exception to the Prompt Payment Policy.