Responsibilities

- Review and assess complex and high-value insurance claims from legal, contractual, and fraud perspectives.
- Identify suspicious claims, policy violations, misrepresentations, and potentially fraudulent activities.
- Conduct claim investigations, including document verification, field investigations, interviews, and coordination with internal/external stakeholders.
- Examine legal documents, FIRs, police reports, medical records, affidavits, and other evidence relevant to disputed claims.
- Coordinate with Legal, Claims, Medical, Risk, Compliance, and Investigation teams to resolve complex cases.
- Support the initiation and follow-up of appropriate legal actions in cases involving suspected fraud or criminal activity.
- Coordinate with police authorities, advocates, and other external agencies as required.
- Assist in the preparation of case briefs, legal notices, investigation reports, and documentation for litigation or regulatory matters.
- Ensure claims are handled in accordance with policy terms, IRDAI regulations, and applicable laws.




- Provide legal and risk inputs on recurring fraud patterns and recommend preventive controls.
- Maintain complete documentation and evidence trails for investigated cases.
- Support fraud analytics to identify emerging fraud trends in health insurance.
- Conduct awareness sessions for claims and operations teams on fraud indicators, legal requirements, and documentation.
- Prepare MIS and management reports covering investigations, fraud detection, recoveries, and legal cases.

Preferred Profile

- LLB degree with relevant experience in insurance, claims, fraud investigation, legal, or compliance functions.
- Strong understanding of insurance contracts, claims processes, and applicable legal/regulatory requirements.
- Proven experience in handling complex claims and fraud investigations.
- Strong drafting, documentation, communication, and negotiation skills.
- Ability to effectively coordinate with police, legal counsel, and internal departments.
- Solid analytical and investigative mindset.

📌 Manager Legal, Claims & Fraud Control (Gurugram)
🏢 Care Health Insurance
📍 Gurugram