INSURANCE FRAUD:
The National Fraud Investigative Service (NFIS) has assisted in the investigation and prosecution of insurance fraud cheats.
We have the experience to detect, investigate and defend against insurance fraud by examining suspicious claims closely for evidence of fraud and by educating our clients to identify suspicious claims.
We are dedicated to fight and defending organizations against Insurancd Fraud.
Definition of Insurance Fraud:
Insurance Fraud occurs when an individual intentionally deceives an insurance company or agent to collect money to which they are not entitled to.
It must be noted that insurance fraud is an intentional act, requiring a material and/or intentional misrepresentation in order to obtain a benefit, or cause a benefit due someone to be denied. In addition, insurers and agents also can defraud consumers or even each other.
There is a difference between claim exaggeration or inflation of a claim and claim fraud. Insurance fraud as we stated needs to have a material misrepresentation in order to obtain a benefit. The misrepresentation must be intentional.
A person can also make a misrepresentation that is not intentional. For example, when conducting the initial loss report, the insured provides a false or wrong answer to the question asked of them. They did so because they misunderstood the question or forgot some incident or fact pertaining to the loss. This might not be an intentional misrepresentation.
Here is an example: During the course of your claim investigation, you asked the subject if he is involved with any outdoor activities. He replies, “of course, in the evening time I started to walk around the block in two times.” When the investigator inquired how far the distance is, the claimant replies, “oh, just a mile.”
During the course of your investigation you later determined that the distance around the claimant’s block is one and one half (1 1/2) mile around. This could very well be an unintentional misrepresentation. The claimant may have estimated the distance and never measured it.
On the other hand, if you were able to obtain documentation of the claimant running and participating in a twenty-six (26) mile marathon on many occasions, then the above statement could be perceived as an intentional misrepresentation, which could have an impact or effect on the claim.
Insurance Fraud Indicator’s or “Red Flag” Checklist:
The following List of Fraud Indicator’s was compiled by the Fraud Analyst’s at the National Fraud Investigative Service (NFIS). The Fraud Indicator List is intended as a guideline or a “Red Flag” checklist. It is not a complete checklist for investigation but does provide some guidance whether an investigation should be conducted.
If a number of these “Red Flags” are identified, Please contact the National Fraud Investigative Service (NFIS) Team, a thorough investigation is warranted.
Claims Fraud Indicators:
• Lack of memory on prior loss information
• Excessive pressure for immediate settlement
• Excessive knowledge of insurance terms/procedures
• Recent increase of policy limits
• Questions to Agent about coverage just prior to loss
• Lack of memory about prior Carriers/Agents
• Reluctant to meet for interviews or provide details of loss
• Retains Public Adjuster or “known” Attorney immediately
• Lack of documentation or “too good” documentation
• Will not use mail system (USC Title 18 Mail Fraud)
• Reluctance to send FAX information (Wire Fraud)
• Refusal to sign Information Releases
• Becomes very nervous when told an investigation will be conducted
• When interviewed, has “rehearsed” story and selective memory or details change
Red Flags of Possible Workers’ Compensation Fraud or Abuse:
If the injured employee:
• Has injuries that are inconsistent with facts of the accident.
• Provides multiple versions of how the accident occurred.
• Refuses medical tests or examinations to confirm an injury.
• Stays out of work longer than the doctor prescribed.
• Protests excessively about a modified position or returning to work and never seems to improve.
• Has a suspicious prior history of reporting subjective injuries.
• Has a questionable identity, residence or contact information.
• Was experiencing financial difficulties prior to submission of a claim and inquires about a quick claim settlement.
• Is retiring, on probation, involved in a labor dispute, disgruntled, a poor job performer or subject to disciplinary action.
• Is a new employee, nomadic, a seasonal worker or on short-term employment.
• Is never at home, does not answer telephone or avoids the use of U.S. Mail.
• Is unusually familiar with the workers’ compensation system or terminology.
If the accident or illness:
• Lacks witnesses.
• Occurs late on a Friday afternoon (especially if not reported until Monday) or early on a Monday morning.
• Is not associated with employee’s job duties.
• Occurred in an area not frequented by employee.
• Is not reported to the employer in a timely way.
• Leads to rumors at work that the accident was staged or illegitimate.
Medical Provider Fraud:
• Canned medical reports and notes
• Errors of an obvious nature such as subject’s gender, race or age
• Diagnosis and treatment don’t match
• Clinic using a P.O. Box or mail drop
• Facility with several names
• Unprofessional letterhead or stationary/photocopied
• Referral to nearby medical testing or clinics
• Answering machine
• Treatment on weekends and holidays
• Clinic diagnoses knew problems
• The work comp and health insurance are both billed
• Same treatment over and over
• Multiple subjects from same loss
• Same diagnosis for all subjects
• Clinic is a good distance from subjects home
• Inconsistency of fees for various services
• Numerous treatments on same day
• Mobile diagnostic operations
• Excessive diagnostic testing
• Subject cannot identify clinic
• Subject cannot explain treatment
Personal Medical:
• Injuries are subjective – soft tissues, sprains, headaches, psychological issues
• Psychological claims for Stress and Anxiety
• Claim is from previous injury
• Excessive recovery time
• Excessive Chiropractic treatment
• Excessive testing – MRI-NCV
• Excessive Therapeutic treatment – massages, acupuncture
• Subject shows no interest in getting better – doesn’t want tests
• Subject visit specific doctors immediately
• Subjects’ vitals are good –despite alleged long term inactivity
• Subject is over dramatic when describing injury
• Conflicting medical opinions
• Medical billings are billed on holidays and weekends
• Treatment includes prescriptions for controlled substances
• Variation in description of pain
General Insurance Fraud Indicators:
• Insured not living or working close to Agency
• Insured lied on prior loss section of application
• Application returned unsigned – willing to pay cash
• Insured used third party to make application
• Reluctance to use mail for information
• Application not signed in Agent’s presence
The National Fraud Investigative Service (NFIS) has the experience and specialized skills to look for “red flags” or indicators that fraud might be occurring.
Contact us today for a FREE CONSULTATION on your claim files.