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Home > Services > Insurance Claims Investigations > Insurance Fraud
 

Insurance Fraud

Indicators of Common Insurance Fraud Claims: Corporate, Litigation Support, Insurance Claims, Fraud, Theft, Wrongful Death, Accidents


Insurance fraud hurts everyone! The insurance companies must raise premiums in order to maintain their bottom line. The smaller companies and self-insured's are paying increased premiums and the consumer is hit hard with higher costs. Fraudulent claims can arise out of automobile, product liability, general liability and workers' compensation accidents. 

Summit Loss Prevention Consulting is here to help. Our more than 25 years of investigative experience can uncover the truth behind fraudulent claims, including fire and theft losses, and exaggerated injuries, to determine what happened, or whether they actually occurred or not.

Indicators of Insurance Fraud

Here's a startling insurance fraud statistic: The Insurance Information Institute estimates that property/casualty insurance fraud cost insurers about $30 billion in 2004. (Editors note: that comes to more than $100 for every man, woman and child in the country.) The following are some of the indicators considered during an investigation of potential insurance claims:

General

  • Recent increase in coverage
  • Loss occurred shortly after inception date of policy or shortly before expiration of policy period
  • Insured verifies existence and extent of coverage shortly before loss
  • Undisclosed duplicate coverage
  • Insured willing to settle for substantially less than the purported value of the claim  in order to speed claims settlement process or to avoid documentation of claim
  • Over-familiarity with claims process
  • Extensive history of similar claims, particularly claims not disclosed by insured
  • Unwillingness by insured to respond to questions concerning the loss or injury or to provide documentation of same.

Commercial Property Loss

  • Any indication that the business is having financial difficulties or has immediate need for funds
  • Deteriorated or outmoded facilities, business is in bad location or deteriorating neighborhood
  • Machinery, production equipment or inventory is obsolete or unmarketable
  • Property is over-insured
  • Unusual presence of combustible material on the premises
  • Unusual handling of combustible materials normally present on the premises
  • Presence of multiple fires, accelerants
  • Evidence that valuable property was recently removed from the premises or relocated to a safer place within the premises
  • Any departure from long-standing routine (failure to activate alarm system; shut-down of sprinkler system; discharge of security guard)
  • No evidence of unlawful entry or evidence of unlawful entry appears to have been      manufactured
  • Real property is heavily mortgaged
  • Business personal property secures multiple and substantial debts
  • Recent history of late payments or default on loans
  • Principals in business have history of business failures
  • Recent expansion of business facilities which caused insured to incur substantial debt; other over-extension
  • Radically differing accounts of accident or manner in which loss occurred, including inconsistent reports from the same person
  • Overlapping ownership of related businesses with inventory moving readily between businesses without adequate documentation
  • Poor economic climate for particular business
  • Damaged property discarded or not readily available for inspection.

Individual Property Loss

  • Insured experiencing marital difficulties, including separation, divorce, substantial child support obligation or recent increase in child support obligation.
  • History of transience when ownership of property lost is inconsistent with transient lifestyle
  • History of gambling or alcohol or drug abuse
  • Insured has spotty work history or extended period of unemployment
  • Poor economic climate for insured's profession or trade
  • Property lost or destroyed was being advertised for sale
  • Loss limited to high ticket or scheduled items
  • Insured's lifestyle is inconsistent with income
  • Value of property lost is inconsistent with insured's income
  • Too many receipts to support claim - for example receipts for small items purchased shortly before loss that would not normally be retained
  • Too few receipts, especially for recently purchased, high ticket items
  • Receipts are suspicious in nature:
    • No store identification on receipt
    • Consecutively numbered receipts
    • Large number of undated receipts
  • Recent movement of valuables or sentimental property to place of safety
  • Unexplained absence of typical household items or non-combustible items at fire scene
  • Unexplained absence of family pet at time incident occurred
  • No evidence of unlawful entry or evidence of unlawful entry which appears to have been manufactured
  • Pattern of past claims or losses
  • Property heavily mortgaged or insured otherwise financially overextended
  • Insured's' movements unaccounted for at time of loss
  • Unexplained departure from habits
  • Radically differing accounts of accident or manner in which Loss occurred, especially inconsistent reports from the same person
  • Damaged property discarded or not available for inspection

Personal Injury

  • Insured/claimant has extensive history of claims/accidents
  • Descriptions of occurrence vary widely or are virtually identical suggesting rehearsal
  • Legal representation sought shortly after injury occurred
  • No treatment sought for injuries until a substantial period of time elapsed after the accident or until legal representation is obtained
  • Course of treatment is questionable:
    • No apparent relationship between injuries claimed and treatment provided
    • Minor injuries result in major medical costs
    • Medical bills are out of balance with treatment obtained
  • Documentation of treatment is suspect:
    • Photocopies of bills supplied, no originals
    • No record of dates of treatment
    • No itemization of treatment provided
  • Majority of complaints are subjective and incapable of corroboration
  • Claim for pain and suffering is not consistent with severity of injuries
  • Long-standing relationship between attorney and treating physician
  • In products cases, injury-producing product has been lost or destroyed

Automobile Accidents

  • Damage to vehicle is inconsistent with injuries claimed
  • Absence of police report where logic dictates that a report should have been made
  • Existence of multiple claimants as a result of same accident whose injuries vary widely in degree
  • Multiple, unrelated occupants in same vehicle
  • Relationship among occupants creates possibility of collusion
  • Multiple claimants obtain representation from same attorney
  • Multiple claimants obtain treatment from same physician and follow similar course of treatment

Workers Compensation Claims

  • Un-witnessed Monday morning accident
  • Claimant can seldom be reached by phone during the day
  • Claimant repeatedly misses or reschedules doctor's appointments
  • Nature and extent of alleged injuries are inconsistent with how the accident occurred and/or doctor's diagnosis
  • The claimant's co-worker has a prior history of workers' compensation or liability claims
  • The claimant is self-employed or has a job that would allow the claimant to work for cash while collecting temporary disability
  • The claimant's employer is experiencing financial or labor difficulties
  • Claimant's job performance is poor and/or claimant has taken significant sick time for unexplained illness

 

For information about conducting a comprehensive insurance fraud investigation, call 317-363-8312, send email to info@SummitLossPrevention.com. or submit the short form below:

   
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