According to ethical guidelines, what obligation does an insurance claim representative have if they suspect fraud?

The obligation of an insurance claims representative who suspects fraud is to report their suspicions to the appropriate supervisory authority. This aligns with the ethical guidelines that emphasize the importance of transparency and accountability in the handling of claims. When fraud is suspected, it is crucial to involve the proper channels to ensure that a thorough investigation can take place and necessary actions can be initiated to protect the integrity of the insurance process.

Reporting to a supervisory authority helps maintain industry standards and upholds the interests of both the insurance company and its policyholders. Handling these suspicions internally ensures that the matter is addressed appropriately and that the representative is acting in accordance with legal and ethical obligations.

While investigating the claim may seem like a direct response to suspicions of fraud, the ethical pathway requires that insurance professionals leverage their organization's existing systems and procedures by reporting their findings to those better positioned to conduct an investigation. This way, they avoid potential conflicts of interest and maintain objectivity, allowing trained personnel to handle the investigation effectively.