When to Use a Complex Claims Investigation

Not every claim follows a straight path to resolution. While many cases move through standard processes, others quickly become more complicated due to medical, operational, or administrative challenges. These are the claims that require closer scrutiny and deeper investigation. A complex claims investigation goes beyond routine file reviews. It’s a strategic approach to uncover hidden risks, clarify conflicting information, and support defensible decisions. With a small percentage of claims driving a majority of costs, knowing when to initiate a complex claims investigation is more important than ever.

What Makes a Claim Complex?

A complex claim typically involves higher financial exposure, extended durations, multiple stakeholders, or unclear facts that make resolution far less straightforward.

Not all claims become complex for the same reason. Some are challenging from the start, while others evolve over time as medical, operational, or administrative issues begin to stack up. What they all share is this: complex claims demand more oversight, deeper investigation, and significantly more resources than standard claims.

Several factors can drive that complexity.

Medical Complexity

Medical issues are among the most common and most difficult sources of claim complexity. These may include:

• Comorbidities such as diabetes, obesity, cardiovascular disease, or autoimmune conditions
• Mental health involvement, including anxiety, depression, PTSD, or chronic pain syndromes
• Conflicting medical opinions between treating providers, IMEs, and utilization reviewers
• Delayed recovery or treatment noncompliance, extending disability duration
• Polypharmacy and opioid use, increasing both clinical and financial risk

Together, these factors can blur causation, complicate treatment plans, and prolong claims well beyond expected timelines.

Operational Complexity

Operational challenges often sit outside a claimant’s direct control, but they still have a major impact on claim resolution. Common examples include:

• Supply chain disruptions delaying medical equipment, prescriptions, or home health services
• Workforce limitations, such as a lack of modified duty roles or remote accommodations
• Multi-location or remote work environments, complicating return-to-work decisions
• Catastrophic events or disasters that create claim volume spikes and resource strain

Even when liability is clear, operational complexity can stall progress and slow resolution.

Administrative & Coverage Complexity

Behind the scenes, administrative layers can quietly escalate a claim’s difficulty. These may involve:

• Multiple policies or carriers tied to a single loss
• Coverage disputes or unclear policy language
• Jurisdictional differences across states or countries
• Legal representation or litigation, increasing documentation and oversight requirements
• Regulatory reporting and compliance obligations

In many cases, these issues require deeper investigation just to determine responsibility and next steps.

The Impact of Complex Claims

Complex claims place a disproportionate strain on insurers and employers. These cases can consume up to 30% of claims resources while generating only about 8% of revenue, creating significant administrative drag and lost efficiency.

In workers’ compensation specifically, complexity is highly concentrated in a small subset of claims, but those claims drive a large share of costs. Risk & Insurance reports that while complex cases make up just 5% of total workers’ comp claims, they account for roughly 28% of overall claim costs. These claims also last significantly longer, with an average disability duration of 64 weeks compared to just 18 weeks for standard claims.

This is where risk, exposure, and resource strain converge, making complex claims one of the most critical areas for strategic oversight and intervention.

What a Complex Claims Investigation Looks Like

When these factors come together, insurers may initiate a complex claims investigation to regain clarity and control. This process often includes in-depth record reviews, claimant and witness interviews, medical and employment verification, and close coordination with legal counsel. In some cases, it may also involve fraud or misrepresentation analysis.

The goal isn’t just cost containment; it’s to support defensible, well-documented claim decisions that stand up to scrutiny.

Example:

An employee reports a back injury after lifting at work. Initial treatment appears routine, but a deeper review reveals preexisting diabetes and obesity that may be contributing to delayed healing. As recovery stalls, the claims team initiates a complex claims investigation. Medical records are reviewed across multiple providers, uncovering conflicting opinions on work restrictions and treatment plans. Employment verification shows inconsistent attendance patterns, and interviews with supervisors reveal limited modified-duty options. When the employee retains legal representation, investigators coordinate closely with defense counsel to document claim developments. Surveillance and social media reviews are conducted to validate reported restrictions. What began as a standard claim now requires ongoing investigative oversight to clarify causation, confirm work capacity, and support defensible claim decisions.

Need expert support for complex claims investigations? Talk to our team to ensure thorough, defensible, and efficient claim handling.