Manager Legal, Claims & Fraud Control

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.
• Strong analytical and investigative mindset. .