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.