Behind the Scenes with a Claims Adjuster: Uncovering the Truth About Auto Insurance
Published Date: 08/20/2024
Behind the Scenes with a Claims Adjuster: What Really Happens After You File an Auto Insurance Claim
When a car accident happens, the moments that follow are often chaotic. Between dealing with damage, injuries, and stress, few people stop to think about what happens next — once they make that call to their insurance company.
In a recent episode of Insurance Hour, host Karl Susman pulled back the curtain on one of the most misunderstood parts of the insurance world: the claims process. Joined by former claims adjuster Rachel Goldman, the two explored how adjusters make tough calls, why some claims take longer than others, and what really determines who’s “at fault.”
Their discussion provided a rare look inside a system that most people only encounter during moments of crisis. What emerged was both surprising and deeply human — a world driven by deadlines, judgment calls, and, yes, the occasional angry phone call.
What Does a Claims Adjuster Actually Do?
“Spell it out for us like we’re stupid,” Susman joked early in the show. “What does a claims adjuster do?”
Goldman didn’t hesitate:
“We get information about what happened in an accident — or if there’s damage to your car — and we figure out who’s at fault. Then we resolve the claim and pay the right parties based on the coverage.”
It sounds simple enough, but the job is anything but. Adjusters are investigators, negotiators, customer service reps, and financial gatekeepers rolled into one. They handle everything from gathering statements and reviewing evidence to coordinating with body shops, medical providers, and sometimes attorneys.
Goldman spent ten years managing auto claims — the most common type of insurance claim in the country. Her work required balancing empathy with efficiency, often while juggling 40 to 100 active cases at any given time.
The Hidden Pressure Behind Every Claim
Few policyholders realize just how much a single adjuster handles.
“There were times where I would have anywhere from 50 to 100 pending claims,” Goldman recalled. “It’s very challenging to handle them effectively, especially when you’re waiting on people to call you back, schedule inspections, or get statements.”
Each case involves multiple moving parts — and every delay can cause frustration on all sides. Adjusters face pressure from both their employers (to resolve claims quickly) and customers (who want fast payouts and empathy).
That balancing act takes discipline. Goldman described using paper calendars, handwritten notes, and early computer systems to stay organized — long before modern automation tools made the process easier.
But even now, the heart of claims work hasn’t changed: it’s still about people, judgment, and timing.
The Myth of the “Evil Adjuster”
One of the biggest misconceptions, Susman pointed out, is that adjusters exist to deny claims or raise premiums.
Goldman laughed at that notion.
“People think we’re trying to show they’re at fault so the carrier can charge them more,” she said. “But that’s not how it works. We don’t assign surcharges — we just determine what happened. Our job is to apply the facts to the policy.”
Still, emotions often run high. Many policyholders assume their insurer should act like a personal savings account — “I’ve been paying you all these years, so you should pay me now.”
“I understand where that comes from,” Goldman admitted. “But that’s not how insurance works. You’re paying for risk transfer, not guaranteed payouts.”
Her insight touches on a key educational point for consumers: insurance isn’t a refund system. It’s a collective pool that protects against unpredictable loss.
Fault, Facts, and Frustration
If there’s one phrase every claims adjuster hears daily, it’s this:
“It wasn’t my fault!”
Determining fault, Goldman explained, is often the hardest part of the job — and the one that upsets policyholders the most.
Some cases are straightforward, like a rear-end collision. But even those can surprise you.
“People will run into a pole and say it wasn’t their fault because the pole wasn’t painted bright enough,” Goldman joked. “Or they’ll say, ‘I dropped my phone and hit something.’ It has to be someone’s fault unless something literally fell out of the sky.”
She recounted how claimants often talk themselves into trouble:
“They’ll say, ‘I saw the other car coming really fast, but I turned anyway.’ And I’ll think, ‘Well, why would you turn in front of them then?’”
In short, honesty matters. Trying to spin the story can easily backfire. Every word you say to your adjuster becomes part of the official claim record.
Attorneys: Help or Hindrance?
The discussion also touched on how involving an attorney can dramatically change a claim’s trajectory.
Once an attorney steps in, the adjuster can no longer speak directly to the client — every communication must go through the lawyer. That adds complexity, delays, and sometimes extra cost.
“You may not end up with more money,” Goldman warned. “You might even end up with less, because now you have to pay the attorney’s fee.”
That doesn’t mean representation is always bad. In serious cases — such as severe injuries or underinsured drivers — legal help can be essential. Goldman shared one example where a passenger injured by a friend’s reckless driving needed an attorney to recover adequate compensation.
The key takeaway? Get a lawyer when the situation is legally or financially complex — not just because you’re frustrated.
The Human Side of Claims
Adjusters hear anger, tears, and confusion daily. Few people ever call them in a good mood.
“It’s probably one of the few professions where you answer the phone and know the person’s not happy,” Goldman said. “Something bad happened, and they’re scared or upset.”
Her advice to consumers? Be kind.
“It’s not going to change the outcome of your claim,” she explained. “But it can change how pleasant or miserable the process feels. Adjusters are human. We respond to how we’re treated.”
While professionalism demands impartiality, Goldman admitted that rudeness can still affect the pace of follow-up. A little empathy, she said, can go a long way.
Fraud: The Dark Side of Claims
No conversation about insurance claims is complete without addressing fraud — and Goldman didn’t shy away from the topic.
She described a type of staged accident called a “swoop and squat.”
“These are people who intentionally get rear-ended,” she explained. “They’ll fill the car with passengers, cut in front of someone, slam on the brakes, and then all claim injury.”
Fraud rings often have lawyers on standby and work with shady medical providers to inflate injury claims. Adjusters are trained to spot red flags — like too many passengers, identical stories, or immediate attorney involvement.
When such claims are flagged, they’re sent to a special investigations unit (SIU) for deeper review. Sometimes, just notifying the claimant’s attorney that the case has been referred to fraud is enough to make the claim disappear.
But even when detected, fraud hurts everyone: it drives up administrative costs, investigation time, and ultimately insurance premiums for honest policyholders.
The Importance of Documentation
When Susman asked how Goldman handled so many simultaneous cases, her answer was simple: documentation.
“Everything had to be clearly documented — every conversation, every date, every promise,” she said. “If another adjuster took over, they needed to know exactly what had happened.”
Thorough notes also help when stories change — which, she noted, happens more often than people think.
“People talk to friends or family who say, ‘You didn’t tell them it was your fault, did you?’ And suddenly, their story changes. That’s why we record statements early — when memories are fresh.”
Her practical tip for policyholders? Take photos immediately after an accident — of vehicle positions, damage, and surroundings. Memory fades, but photos don’t.
Who Does the Adjuster Really Represent?
Perhaps the most revealing moment came when Susman asked:
“When you’re dealing with your insurance company’s adjuster — whose side are they on?”
Goldman’s answer cut through years of public skepticism:
“We represent the insured — you — but we also represent the law and the coverage. We’re not on anyone’s side. We look at the facts and apply the policy.”
In other words, adjusters aren’t adversaries; they’re referees bound by policy language.
Understanding that distinction can change how consumers view their relationship with insurance companies. Policies are contracts, not personal favors — and adjusters are there to enforce them fairly.
The Best Advice: Be Prepared and Stay Calm
In her closing thoughts, Goldman offered practical guidance for anyone facing a claim:
“Take pictures. Write down what happened. Get names of witnesses. Have your facts straight before calling. And remember, the person on the other end is just doing their job.”
Susman echoed the sentiment in his closing message to listeners:
“Insurance might not be the most exciting topic in the world, but understanding it matters more than ever. Things are more complicated than they used to be — and you need to know more than you used to.”
Key Lessons for Policyholders
- Adjusters aren’t out to get you — they’re bound by law and coverage rules.
- Documentation is your best defense. Take photos, keep notes, and be honest.
- Kindness pays off. Courtesy won’t change fault, but it will make the process smoother.
- Fraud hurts everyone. Staged accidents and inflated claims drive up premiums for honest consumers.
- Legal help has its place — but know when you truly need it.
- Insurance isn’t a savings account. You pay for risk protection, not guaranteed payouts.
Final Thoughts
The next time you file a claim, remember: there’s a real person on the other end of the phone — one managing dozens of cases, navigating laws, and trying to get you back on the road.
Auto insurance isn’t just about cars and collisions; it’s about trust, communication, and shared responsibility. Understanding how the process works — and what adjusters actually do — can turn a stressful experience into an informed one.
Because as Insurance Hour reminds us every week,
the more you know about insurance, the more empowered you are to protect what matters most.
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