hardDesignCase StudyMidSeniorStaff
How would you detect insurance fraud, and how is detecting it at claim different from detecting it at application?
Insurance fraud detection differs at application and claim. Application fraud checks declared risk data at quote time; claim fraud combines claim scoring, entity resolution, network analysis and investigator queues sized to SIU capacity.
5 min readUpdated 2026-08-15
Answer
Short answer
Detect application fraud by checking declared facts against external, historical and behavioural data before policy issue. Detect claim fraud by scoring the claim, resolving related parties, finding suspicious networks and routing evidenced referrals to investigators. The design must respect latency at quote time and SIU capacity at claim time.
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Likely follow-ups
- How do you stop a fraud model from decaying as the rings adapt to it, and how would you know it had?
- What would you deliberately not automate here, and on what grounds?
- How do you evaluate a fraud model when you can only ever observe outcomes for the cases you referred?
- Where do industry-shared databases fit, and what changes about the design when you can query one?
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