Ocean Point Claims:how insurers evaluate claims internally

How Insurance Companies Evaluate Claims Internally

Every claim filed in Florida enters a carrier's internal evaluation process the moment it's reported. Knowing how that process works, reserves, authority limits, supervisor reviews, SIU triggers, changes how a policyholder documents and communicates. This guide is written from former-carrier experience.

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Reviewed by Eli Goins, FL DFS License #P159790 · Last updated April 6, 2026

By Eli Goins · FL DFS #P159790 · Reviewed: April 6, 2026 · 2 min read

Short answer: Insurers process claims through internal stages: a First Notice of Loss (FNOL) is logged and routed, a reserve (estimated payout) is set, then a desk adjuster reviews the file within their authority limits. Larger or complex claims escalate to supervisors, and suspicious ones go to the Special Investigations Unit (SIU) before a final pay or deny decision.

Stage 1: FNOL intake and routing

First notice of loss is taken by an intake rep (usually a call center). The claim is classified by type (water, wind, fire, liability), severity tier, and routing destination. Severity classification drives which adjuster tier handles the file.

Stage 2: Reserves

Within 24-72 hours of FNOL, a reserve is entered: the carrier's estimated exposure on the claim. Reserves affect:

Which adjuster level handles the file (junior vs. senior)
Whether SIU (Special Investigations Unit) reviews for fraud indicators
Whether the claim escalates to large-loss team
Internal budgeting and reinsurance calculations

Reserves are adjusted as the claim progresses. Low initial reserves that get raised aggressively often signal the claim is being re-scoped upward.

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Stage 3: Adjuster authority limits

Every field/desk adjuster has a dollar-amount authority ceiling: often $10K, $25K, or $50K. Claims exceeding authority require supervisor approval, which creates internal friction and is used strategically to pace payouts.

Stage 4: Desk adjuster review

The field adjuster's scope note and Xactimate estimate go to a desk adjuster who reviews line by line. Desk adjusters apply:

Standardized pricing checks
Depreciation tables
Coverage-form comparisons
Policy-condition compliance review

Desk adjusters often override field adjuster scope down, rarely up.

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Stage 5: Supervisor / manager escalation

Large, complex, or contested claims escalate to supervisors. Typical escalation triggers:

Reserve above threshold
Policyholder represented by counsel or PA
Coverage dispute
Potential fraud indicators
Civil Remedy Notice filed

Stage 6: SIU referral

Special Investigations Unit reviews suspicious claims. Triggers:

Inconsistent loss-date / damage-pattern evidence
Prior claim history
Policy effective-date proximity to loss
Common-indicator clusters (e.g., multiple vehicle / property claims)

SIU is not necessarily adversarial but dramatically slows the claim timeline.

Stage 7: Pay / deny decision

After internal review, the carrier issues a decision. For denials, a legal or senior-adjuster review typically signs off on the denial letter.

What this means for policyholders

Document thoroughly at the first inspection. Field adjusters can't document what they don't see.
Assume the desk adjuster will look for reasons to reduce scope. Every line item should be defensible.
Expect delay when you escalate. Attorney / PA involvement triggers supervisor review, which adds days or weeks.
Don't provide ambiguity. SIU referrals are fishing expeditions: clean documentation avoids them.

Frequently asked questions

What is a claim reserve and does it affect my payout?

A reserve is the internal dollar amount an insurer sets aside to cover your claim once your FNOL is logged. It is an accounting estimate, not an offer, and it is not disclosed to you. Because adjusters often work toward the reserve, an early low reserve can anchor the whole evaluation, which is why thorough documentation from the start matters.

Why was my claim sent to the Special Investigations Unit (SIU)?

Insurers route claims showing certain red flags, such as inconsistencies, prior losses, timing concerns, or large amounts, to the SIU for closer review. An SIU referral is not an accusation, but it can slow the process and trigger requests for recorded statements and documents. Florida's claim response deadlines under 627.70131 still apply, and a referral does not give the insurer unlimited time to decide.

What does adjuster authority mean, and why does my claim keep getting escalated?

Each adjuster can approve payments only up to a set dollar authority limit. When your claim exceeds that limit or involves a coverage dispute, it escalates to a supervisor or manager who must sign off. This is normal internal routing, but it adds delay, and decisions made above the desk adjuster's level are where many denials and underpayments originate.

How does the insurer's internal process affect what I should document?

Because desk adjusters evaluate your claim largely from the file rather than by standing in your home, the evidence you submit drives the outcome. Detailed photos, itemized damage lists, and written communications give the adjuster less room to underpay within their authority. Strong documentation also supports you if the claim escalates or you later pursue DFS mediation under 627.7015.

What happens after the internal review, and how long does the insurer have to decide?

After review, the insurer issues a pay, partial-pay, or deny decision. Under Florida law (627.70131), the insurer must acknowledge your claim within 7 days, begin its inspection within 30 days, and pay or deny within 60 days of receiving notice. If you disagree with the outcome, options include DFS mediation under 627.7015 or a Civil Remedy Notice under 624.155 for bad faith.