Fraud Indicators

Our years of experience have shown that these indicators can help identify fraud schemes. No indicator by itself is necessarily suspicious and the presence of any indicator does not firmly establish that a fraud has been committed.  However, closer scrutiny of the claim is necessary.

FRAUD INDICATORS: WORKER’S COMPENSATION

RECOGNIZE SUSPICIOUS CLAIMS 

SUSPICION THAT EMPLOYEE MAY BE WORKING ELSEWHERE WHILE RECEIVING BENEFITS

  • Adjuster has difficulty reaching claimant at home during the day
  • Claimant offers no permanent address or has frequent relocations while receiving benefits
  • Claimant frequently cancels or misses doctor or therapist appointments
  • A potential new employee for claimant calls to verify previous employment
  • Tip has it that claimant is presently employed elsewhere

SUSPICIOUS MEDICAL TREATMENT

  • Physician has reputation for handling suspicious claims
  • Prolonged or excessive treatment received for minor injury
  • Discrepancies exist between treatment or medication and claimed injury Sketchy details listed on medical bill
  • Medical bills are photocopies, not originals
  • Claimant received unnecessary hospitalization
  • Claimant visits several doctors (possibly in search of a medical opinion that favors the claim)
  • Physician directs treatment to occur at a facility where he has a financial interest
  • Bill lists a treatment date that is a holiday
  • Bill is inflated due to “unbundling” – billing for each step of medical procedures
  • Medical reports appears exactly the same as other reports from the same physician
  • Insurers for both workers’ compensation and group health are billed simultaneously and payment is accepted for both

SUSPICIOUS ENGAGEMENT OF LEGAL ASSISTANCE

  • Your first notice of claim is by an attorney or you learn that the claimant has hired an attorney immediately after filing the claim
  • Attorney lien or representation letter is dated the day of
  • Attorney suggests a settlement or buy-out soon after claim is filed
  • Claimant initially shows willingness to settle with insurer but later hires an attorney and files subjective complaints
  • Attorney threatens further legal action if quick settlement is not made
  • Claim involves excessive demands for compensation of a permanent injury
  • Attorney has a reputation for handling suspicious claims
  • Your company experiences a high number of suits from a specific law firm
  • The same combination of attorneys and medical providers involved in previous claims recurs

SUSPICIOUS ACCOUNT OF ACCIDENT

  • No specific date, time and place for injury or claim
  • Details of injury reported on claim are sketchy at best
  • Claimant does not promptly report injury to supervisor
  • Discrepancies between claimant’s account of injury and medical evaluation
  • Discrepancies between claimant’s account if injury and witnesses’ accounts
  • Injury is unwitnessed
  • Co-workers share rumors that accident is illegitimate
  • Reported accidents occurs in an area where claimant does not work
  • Claim may be part of a suspicious pattern of claims from the same area or location

SUSPCIOUS TIMING OF CLAIM

  • Injury is reported as occurring on a Monday or Friday (injury might have occurred away from workplace or claimant may use claim to extend weekend)
  • Claim occurs prior to anticipated layoff, termination, strike or retirement
  • Claim occurs after claimant has been terminated
  • Claim occurs shortly after employee was hired
  • Claim occurs after injured worker took unexplained or excessive time off
  • Injury is “seasonal” before seasonal layoff or is recurrent (claimant has pattern of reporting an injury before a vacation)
  • Claimant is having financial difficulties
  • Claimant has been complaining about his job, supervisor or the company
  • Claimant recently purchased a private disability policy

SUSPICIOUS NATURE & EXTENT OF INJURY

  • Type of injury is unusual in claimant’s line of work
  • Injury concerns soft tissues and cannot be objectively verified
  • Discrepancies exist between injury and facts of the accident
  • Claimant refuses diagnostic procedures to confirm injury
  • Claimant refuses to cooperate with rehabilitation personnel
  • Claimant refuses to return to work despite doctor’s OK to return
  • Claimant files for compensation because of vague complaints of stress
  • Claimant has history of reporting subjective injuries (such as headaches, nausea & sleeplessness)

FRAUD INDICATORS – BODILY INJURY

RECOGNIZE SUSPICIOUS CLAIMS 

SUSPICIOUS BODILY INJURY CLAIMS

  • No police report or on-scene police report
  • Several claimants in same vehicle, subjective injuries, similar reports, same doctors and/or same attorneys
  • Bodily injuries appear excessive compared to the amount of physical damage to the auto
  • Accident is a rear end collision caused by a sudden, unjustified stop by the claimant’s car
  • Accident occurred shortly after one or more of the vehicles was purchased, registered or insured
  • Insurance feels “set up” by claimant(s)
  • Claimant’s work place phone number connected to answering machine or registers to an answering service or mail drop
  • Slight impact; subjective injuries (soft tissue); substantial treatment and excessive demands
  • Questionable dates of treatment, evidence of alteration of dates and/or charges
  • Slip and fall with no witness or the witness is unusually observant
  • A company name on a lost wage statement cannot be located, there is no record of said employee at that company and/or the company is owned by claimant’s relative
  • Claimed ailments persist far beyond normal recuperative time period
  • Insured takes out a new policy even though the insured vehicle was purchased long before coverage was sought
  • Doctor’s mode of treatment, duration of treatment always the same even though injuries/ accidents differ
  • Designated doctors and lawyers have known history of bodily injury claim involvement
  • Location of doctor/therapist inconvenient to claimant
  • Doctor making house calls beyond convenient distance
  • Wage documentation is lost, not on letterhead of its handwritten or photocopied; includes questionable earnings; difficult to verify
  • Presence of damaged items (props) found (claimed) as damaged
  • Insured is eager to accept blame for the accident
  • Vehicle is a “beater” – an old car with basic coverage
  • Vehicle damage, although minor, “totals” the car

GENERAL INDICATORS OF SUSPICIOUS CLAIMS

  • History of claims activity
  • Familiar with insurance claim terms and procedures
  • Refrains from using the mail of fax; conducts business in person
  • No police report or on-scene report
  • Aggressive demands for a quick settlement, sometimes for less than full value of claim
  • Threatens to contact higher company authority to push demands
  • Temporary address used – post office box or motel
  • Recent policy or walk-in business
  • Photocopied support documentation or computer generated invoices
  • Insured’s employer address is a post office box
  • Unreasonable delay in reporting loss
  • Refuses to give recorded or written statement
  • Self-employed in vague occupation; reluctant to produce tax records
  • First notice of claim and/or immediate attorney representation
  • Recent changes in coverage/inquiries to agent
  • Loss occurs immediately before or after policy renewal/inception dates
  • Claimant experiencing financial problems
  • Discrepancies between official reports of incident and statements made by insured/claimant
  • Lifestyle inconsistent with observation and facts
  • Insured/Claimant wants a friend or relative to pick up check
  • Over documentation of loss
  • Insured/Claimant has no phone
  • Claimant is transient or out-of-towner

FRAUD INDICATORS – MOTOR VEHICLE

RECOGNIZE SUSPICIOUS CLAIMS    

SUSPICIOUS MOTOR VEHICLE CLAIMS

  • Cash purchase of late model or new vehicle
  • Behind in payment to lien holder
  • Out-of-state purchase
  • Individual named as lien holder
  • Insured has no bill of sale or the bill of sale is out of line with the car’s value
  • Vehicle is totally burned
  • Vehicle Identification Number (VIN) of the damaged car does not match the VIN of the insured car or match the model shown in appraisal photographs
  • NICB cannot match VIN
  • VIN plate is different than VIN on the title
  • Vehicle was rebuilt
  • Prior loss or salvage on vehicle
  • Prior owner cannot be located
  • All vehicles in accident taken to the same body shop
  • Recently duplicated or assigned title
  • Counterfeit title documentation
  • Insured claims expensive equipment and items
  • Vehicle has poor reputation (defects, recalls, performance, etc.)
  • Neighbors, friends and relative have no knowledge of vehicle
  • Car has not been seen for some time prior to theft
  • Insured is unemployed
  • Insured wants to retain title to salvage
  • Loss takes place between insurance of binder and state-mandated pre-inspection (where applicable)
  • Premium paid in cash
  • Comprehensive coverage only
  • Duplicate coverage
  • Repair shop estimates include repairs that body shop is not equipped to make (painting, straightening)
  • Body shop has history of high damage claims
  • Appraiser/adjuster is threatened or offered a bribe for quick settlement
  • There is heavy property damage to the vehicles indicating a major collision but no bodily injuries are reported
  • Salvage or repair shop takes active interest in claim
  • Repair or installation bills are numbered consecutively or dates show work done on Sundays or Holidays
  • Two vehicles are involved with heavy damage to struck vehicle and relatively light damage to striking vehicle
  • The striking vehicle is a rented car
  • Accounts of the accident by drivers, passengers and witnesses appear rehearsed or are conversely inconsistent
  • Appraisal photography show only close-ups of the damage, but not enough of the car to identify make and model
  • Vehicle is recovered and ….
  • No ignition or steering column damage
  • Carefully stripped lug bolts & washers put back
  • Extensive body damage and no towing charges; vehicle remains drivable
  • Car shows signs of previous damage
  • Damage does not match type of accident claimed

GENERAL INDICATORS OF SUSPICIOUS CLAIMS

  • History of claims activity
  • Familiar with insurance claim terms and procedures
  • Refrains from using the mail of fax; conducts business in person
  • No police report or on-scene report
  • Aggressive demands for a quick settlement, sometimes for less than full value of claim
  • Threatens to contact higher company authority to push demands
  • Temporary address used – post office box or motel
  • Recent policy or walk-in business
  • Photocopied support documentation or computer generated invoices
  • Insured’s employer address is a post office box
  • Unreasonable delay in reporting loss
  • Refuses to give recorded or written statement
  • Self-employed in vague occupation; reluctant to produce tax records
  • First notice of claim and/or immediate attorney representation
  • Recent changes in coverage/inquiries to agent
  • Loss occurs immediately before or after policy renewal/inception dates
  • Claimant experiencing financial problems
  • Discrepancies between official reports of incident and statements made by insured/claimant
  • Lifestyle inconsistent with observation and facts
  • Insured/Claimant wants a friend or relative to pick up check
  • Over documentation of loss
  • Insured/Claimant has no phone
  • Claimant is transient or out-of-towner

FRAUD INDICATORS – PROPERTY & FIRE

RECOGNIZE SUSPICIOUS CLAIMS    

SUSPICIOUS PROPERTY & FIRE CLAIMS PROPERTY

  • Building and/or contents were for sale at time of loss
  • Receipts allegedly stolen or destroyed
  • Insured had loss at same site within preceding year, but the prior loss, though small, may have failed to liquidate the contents
  • Insured is heavily in debt
  • Insured refuses replacement in items
  • Loss occurs at night or early morning hours
  • Risk is over-insured
  • Public officials indicate the loss is suspicious
  • Insured and/or family away from premises at time of loss
  • Items claimed in loss recently scheduled or added to policy
  • Changing neighborhood
  • Loss includes large amount of cash
  • Alarm system failed to work at time of loss
  • Loss inventory includes high number of recently purchased “big ticket” items
  • Insured cannot recall place and/or date
  • Insured(s) balk at signing releases
  • Commercial loss involved seasonal inventory
  • Business/home for sale/moving
  • Inventory obsolete

FIRE CLAIMS

  • Building in deteriorating condition and/or located in a deteriorating neighborhood
  • Fire scene reveals absence of expensive items normally found in risk
  • Absence of family Bible, family photos or any other items of sentimental value
  • Absence of other items normally found in homes or business
  • Responding police/fire personnel report all doors, windows and means of entry/exit were secure
  • Clocks, candles or other timing devices found at scene
  • Items that usually don’t burn (I.e. jewelry, firearms, coins, etc.) are missing from debris
  • Obsolete inventory substituted for modern general inventory prior to loss
  • Incendiary fire identified
  • Lack of forcible entry to premises, yet all keys (including alarm) are accounted for
  • Accelerant identified is foreign to the premises and no container or other means of starting a fire are found at the scene
  • Multiple points of origin in key location and/or throughout premises
  • Alarm/sprinkler system turned off or inoperable at time of loss
  • Insured’s whereabouts at time of loss is questionable or varies from normal routine
  • Fire occurs while property is vacant or unoccupied
  • Family pet survives the fire of is unusually absent from Premises
  • Insured uses fire as means to break tenant/lease agreement

GENERAL INDICATORS OF SUSPICIOUS CLAIMS

  • History of claims activity
  • Familiar with insurance claim terms and procedures
  • Refrains from using the mail of fax; conducts business in person
  • No police report or on-scene report
  • Aggressive demands for a quick settlement, sometimes for less than full value of claim
  • Threatens to contact higher company authority to push demands
  • Temporary address used – post office box or motel
  • Recent policy or walk-in business
  • Photocopied support documentation or computer generated invoices
  • Insured’s employer address is a post office box
  • Unreasonable delay in reporting loss
  • Refuses to give recorded or written statement
  • Self-employed in vague occupation; reluctant to produce tax records
  • First notice of claim and/or immediate attorney representation
  • Recent changes in coverage/inquiries to agent
  • Loss occurs immediately before or after policy renewal/inception dates
  • Claimant experiencing financial problems
  • Discrepancies between official reports of incident and statements made by insured/claimant
  • Lifestyle inconsistent with observation and facts
  • Insured/Claimant wants a friend or relative to pick up check
  • Over documentation of loss
  • Insured/Claimant has no phone
  • Claimant is transient or out-of-towner