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May K. Toney
07-09-2003, 08:13 AM
crime of the time
Seeing Through
False Bodily Injury Claims
By Tony Kulik, CIFI, FCLS, CFI, Special Investigations Unit, Chubb Group of Insurance Companies

Opportunistic bodily injury fraud occurs when there is a legitimate accident, but the injury has either been fabricated or exaggerated. It is a real dilemma for the insurance industry and it requires intense investigation.

For years, the insurance industry classified these types of claims as "nuisance claims." Plaintiff attorneys know this and therefore attempt to negotiate settlements knowing their clients are either exaggerating or fabricating their injuries. These attorneys know which insurance carriers are easy marks for negotiating settlements. To overcome this dilemma, insurance carriers need to have aggressive protocols in place to ensure that a strong preliminary investigation and a continuous follow-up investigation are conducted to suppress these types of claims.

The insurance carriers who implement a team process that will impact the results of denying or mitigating opportunistic bodily injury fraud will have a reputation on the street with plaintiff attorneys that they are no "easy target." Most plaintiff attorneys do not want to go to trial. They lack experience in trying cases not to mention the time consumed at trials. What they really want is the quick settlement from the insurance carrier. They are looking for the quick buck.

Auto injury claims can be complex and they take time to resolve. It is not a simple matter to determine whether a fraud has actually transpired. Red flags or fraud indicators can be used to detect suspicious claims, but the task of proving fraud generally requires intensive investigation that goes well beyond what is possible in the course of routine claim handling.

The primary purpose of screening claims is to reduce unwarranted losses. Achieving this goal requires a proactive mindset in which potential fraud is intercepted at the front end. A reactive posture is not suited to this objective. Improved decision making is another key. Management must recognize the need to thoroughly investigate these types of claims.

BENEFIT ANALYSIS
Insurers and their customers will reap the benefits of significant loss cost reduction and greater customer satisfaction. Productivity will be a natural by-product of improved decision making. The focus will be on making the right decision rather than just closing claims.

Insurers have been seeking ways to reduce unnecessary losses without impairing quality. The key is to improve the claim process by ensuring that the brightest adjusters handle these types of claims.

Claim processing requires that each claim will be viewed in terms of validity, exposure, investigation and defense costs. The handling of a claim will vary, depending on the characteristics revealed. Each claim has to be evaluated on its own merits to avoid bad faith.

FRAUD SCREENING
Early fraud screening is essential. Suspicious potentially fraudulent claims need to be identified quickly. It is not a simple task to determine whether a fraud has actually transpired. Fraud indicators only suggest which claims are suspicious or even highly suspicious. The task of proving fraud generally requires intensive investigation that goes well beyond what is possible in the course of routine claim handling.

Research has shown that fraud indicators cannot prove fraud, but they can be used to separate suspicious claims from non-suspicious claims. The suspicious claims can be directed along various appropriate resistance tracks. A claim denial or even prosecution may ultimately result. However, by responding early, it may be possible to deter or limit the fraudulent activity. The clearly non-suspicious claims can be expedited; freeing up resources currently expended on claims that possess minimal savings potential.

The primary purpose of fraud screening is to reduce unwarranted losses. Achieving this goal requires a proactive mindset in which potential fraud is intercepted at the front end. The traditional reactive posture is not suited to this objective.

SUGGESTED PROGRAM STRATEGIES
Identification
Investigation
Resistance
Disposition
IDENTIFICATION
Once a claim has been identified as meeting the characteristics of opportunistic bodily injury fraud, it is essential that the insurer immediately undertake efforts to investigate the claim and deter the claimant from seeking legal counsel and padding their medical treatment.

It is in the insurer's best interest to be aggressive and modify the claimant's behavior as early on in the claim process as is possible. The intent is to have a speedy response to the claimant before he/she is entrenched in a position to move forward in exaggerating and padding their medical treatment.

Early intervention will hopefully help in curbing unnecessary medical costs. If a claimant is educated that his/her efforts to defraud the insurer will be unsuccessful, through early intervention, he/she may forego needless medical treatment.

INVESTIGATION
The adjuster needs to intensify his/her efforts to determine the truth behind the claim. The intensified investigation should focus on the medical aspects of the claim, since this is where the opportunity lies. The investigation process can also contain elements that will further assist in the resistance process.

A thorough investigative process ensures an accurate assessment based on the merit and value of each claim. The extent of the investigation will differ depending on the circumstances of each accident and may change as the investigation continues.

As one investigates a suspected opportunistic claim, they should always be alert to claims that have characteristics of planned fraud. These claims should be referred to the SIU as early as possible in the claims handling process.

INVESTIGATIVE PROCESS

Attempt to substantially complete your investigation within the first 60 days;

Verify the identity of all claimants and witnesses;

Use medical authorization to seek information from a variety of sources (family doctor, employer, health insurer, HMO);

Take detailed recorded statements (get more details regarding medical treatment, injury and bio-mechanics of accident);

Seek out and obtain recorded statements from insured, witnesses, police, EMT's, tow truck operators, etc. with an emphasis on the claimant's activities at the accident scene, complaints of injury, etc.;

Verification to determine truthfulness of all attorney or claimant supplied information (including comparison of medical bills to medical records and comparison of detailed recorded statements with medical records);

Effective activity checks;

Use of IME's;

When no lost time is an issue, do an extensive investigation of the claimant's work-related abilities during time of treatment/injury.
RESISTANCE
If a belief exists that possible opportunistic fraud will occur, the written and verbal messages to a claimant or attorney should demonstrate that. Although it must be stated, that the claim will be properly and fairly adjudicated with close scrutiny.

RESISTANCE PROCESS

Extensive photograph and inspection of vehicle by the auto damage appraiser, with claimant present, if possible, will indicate potential of bodily injury damages;

Send photographs of the autos involved in the accident to the claimant or his/her counsel; these may show that the minimal physical damage in the accident could not have resulted in significant bodily injury damages;

Request from the claimant or claimant's attorney a medical authorization, a recorded interview and an IME. If the request is ignored, follow-up quickly with additional requests;

Frequent and continuing communication with the claimant's medical provider(s) assuming an authorization exists.
If the claim ceases to appear opportunistic, you can consider changing your investigative strategy to a more routine handling process

May K. Toney
07-09-2003, 08:16 AM
You can probably tell that I've discovered numerous links on the Internet and many are great for keeping up on current events. As a claims adjuster, the story also has special meaning to me. For one, it explains why my desk was never clear and why an adjuster's job is never done. I've only posted a portion of the Crime of the Time story to save space but the remainder of the story is equally fascinating. I highly recommend anyone explore this link. It's informative and packed with other useful information as well. Enjoy!

http://www.claimspages.com/

For some reason I couldn't get the direct story link to work properly. So, to access the rest of this story, click on the above link then select News then type "investigations" in the search area and click "Go". Select : 1/5/2003 Seeing Through False BI Claims - IASIU and there you are.

Mr Jose Bonavich Jr
07-09-2003, 08:02 PM
May,

Thanks for the story and the link info :) . Has anyone told you lately what an assest you are to IPIU. You constantly post new and interesting information in addition to welcoming new members :D ...You are my inspiration for my own progress here at IPIU....Keep up the great work and thanks again for the link info.

May K. Toney
07-09-2003, 09:50 PM
Originally posted by Leisl D Olson
May,

Thanks for the story and the link info :) . Has anyone told you lately what an assest you are to IPIU. You constantly post new and interesting information in addition to welcoming new members :D ...You are my inspiration for my own progress here at IPIU....Keep up the great work and thanks again for the link info.

Alright, I'm blushing with embarrassment, now and I'm all choked up. How kind of you to think that I bring something of value to the membership. I'm just trying hard to show my appreciation to all those here and outside IPIU that have been so gracious and helpful to me in my life and career. I've truly been blessed and thank God every day for His mercy and grace.

Ordinarily, I prefer to work behind the scenes and out of the spot light. But there's something about the atmosphere here that causes me to step forward. My PI peers have just brought out the best in me. . I don't take compliments well. But I'd rather be recognized for building someone up, than tearing someone down.

I've found many inspiring people here. It touches me that you count me among them. I believe you are too!

http://www.webgif.com/cartoni_ani/fan15.gif

Deborah Siehl -
07-11-2003, 06:11 AM
Hi May,

Great story. It is so hard to believe that people will go to these lengths and for what, money and once caught, some go to jail and some probably receive probation.

Insurance fraud seems like a good area to go into, with all the different types out there.

I listened to a special about the staged auto accidents so people can gain illegally from it.

This field is like a big ball field.

Take care and have a great day.

Deborah Siehl

May K. Toney
07-12-2003, 02:34 AM
Originally posted by Deborah Siehl
It is so hard to believe that people will go to these lengths and for what, money and once caught, some go to jail and some probably receive probation.This field is like a big ball field.

Hi Deborah,

I agree that it's hard to believe there are people willing to risk so much for so little. As an adjuster, I learned that many people believe fraud is the fastest path to wealth and security. In a troubled economy, they see fraud as more guaranteed, tax free income - more lucrative than company-sponsored 401k, pension or retirement plans. As long as this attitude continues to spread, fraudulent crimes will continue to increase.

People who defraud insurance carriers and other commercial businesess don't realize or care that fraud adversely effects everyone. Otherwise, they would realize that fraud causes many of the same problems they're trying to escape. In the interim, fradulent practices have become the rule, rather than the exception. The field is certainly wide open and loaded with limitless possibilities for crime fighters.

Thank you for your comments. Take care.

Don Menard
07-29-2003, 02:34 PM
Originally posted by Leisl D Olson
May,

Thanks for the story and the link info :) . Has anyone told you lately what an assest you are to IPIU. You constantly post new and interesting information in addition to welcoming new members :D ...You are my inspiration for my own progress here at IPIU....Keep up the great work and thanks again for the link info.


May,

Leisl has done a great job of summing up your work. I have read many of your posts and I agree with her. Great job.

Michael Harris
08-01-2003, 02:18 PM
May,

Thanks for the great info.

In one of the Sue Grafton Kinsey Milhone (sp?) novels, our heroine examines one of these cases -- a ring of crooks, crooked chiropractors, and crooked lawyers:rolleyes: . I would like an experience fraund investigator to let us know if the treatment in the novel is possible, or if possible, prevalent. I see fiction as a way of teaching, if the novelist did proper research.

I do not have the details anymore, but I live near Philadelphia (the nation's insurance fraud capital). The insurance industry, in conjunction with the local police and transit company, staged a fake bus accident on a major downtown street. The bus and the car that was hit were part of it. 17 (count them, 17) people got on the damaged bus, fell on the floor, and claimed to be injured passengers. All 17 were arrested and charged with insurance fraud.:cool:

Sometimes the good guys win.

Diane Jarosz
08-07-2003, 11:12 AM
Dear May,
You find the best stories!

Thank you for the links.

DJ

Robert Smith -
08-08-2003, 06:26 PM
Great story. Thanks for the link.

Rod Elliott
08-08-2003, 08:34 PM
May,

Thank you for the story. Because of the people that do commit fraud, my insurance premiums go up. I sure hope the companies get tough, it could save us all a buck or two.

Then there are the insurance companies themselves that cause me some concern, especially my health insurance company.

Rod

May K. Toney
08-20-2003, 12:44 AM
Originally posted by Rod Elliott
Thank you for the story. Because of the people that do commit fraud, my insurance premiums go up. I sure hope the companies get tough, it could save us all a buck or two.

Then there are the insurance companies themselves that cause me some concern, especially my health insurance company.

Rod

You're welcome Rod. The people who commit fraud choose to believe that they are not hurting anyone but the non caring insurance companies. If they only knew, or cared themselves, we would all feel some relief in our pocketbooks. :). Thank you for sharing.

Brenda Muller
08-20-2003, 12:16 PM
Hi May, Thank you for the story, What amazes me is all the people that do the fraud crimes think there invisable and that they will never be caught and think everyone is out to get them so they use revenge by doing fraud crimes..To make them feel better about themselves and actually make it worse for you and I.
But Remeber in the end we are the WINNERS..:)
Brenda :)

Michael Harris
08-20-2003, 04:25 PM
Originally posted by Brenda Muller
...all the people that do the fraud crimes think there invisable and that they will never be caught and think everyone is out to get them so they use revenge by doing fraud crimes...
Hi Brenda,

W-EL-C-O-M-E to IPIU and the IPIU forums! :) :D :cool:

The artists do get caught occasionally, but not often enough. They can continue to run against greedy people. :o :( :p

May K. Toney
08-21-2003, 02:06 AM
Brenda, Michael,
I like the way you think and couldn't agree with you more.

Michael Harris
08-21-2003, 07:46 AM
May,

It is nice to know that great minds think alike (at least on limited subjects). :) :D :cool:

Brenda Muller
08-21-2003, 10:00 AM
May
Thanks you...I'm glad to see others feel the same way I do...And this is why we applied to be PI's....So we can Help out by making our world a better place.
Have A Great Day to All
Brenda :)

Colleen L Hayes -
08-22-2003, 12:25 AM
Hi May,

Thank you for that story. Unfortunately, people like that make it hard on the people that are really hurt.

I suffer(ed) a work injury called repetitive stress syndrome. I'm sure every one has heard of it. It comes on gradually and then it is really hard to take care of, let alone diagnose. I went to 2 doctors in California who diagnosed it as cervical and thoracic strain. I sat in a chair, on the phone and computer for 8 hours, the last 4 1/2 hours without a break. I was placed on Work Comp for 6 months and ended up moving down here to Arizona. I saw 2 doctors here (of course they were the insurance company doctors) who informed me "I was out of shape and needed to get back to work". The second doctor, a specialist, I was sent to see for my rotator cuff and shoulder tendinitis. He not only didn't observe my shoulder or take an x-ray like he was requested to do, but he said I should see someone for my depression. I wasn't depressed until that moment.

To make a long story a little less long, I was informed I could return to work as long as I did no sitting for more than 20 minutes at a time without a break and if my workstation was ergonaumically set up. I ended up moving back up to where I had lived to go back to work for the same company, doing the same job (without the ergonaumic set up and without the break every 20 minutes) to get hurt even worse.

There was a good reason for me doing this. If I didn't go back, then my employer would be off the hook. I had informed them 5 months prior to me going out on Work Comp the first time that I was having problems. He ignored me. I wrote a letter to the Office Manager (his mother) and informed her. When I came into work the next day I was called into his office and was informed that as long as I could type with one finger I was not disabled. He also informed the sales manager the year prior to that, that he wasn't going to do any ergonaumic changes, if the employees wanted it they could pay for it themselves.

Needless to say it took four (4) days for my back to have a flare-up to the point of excrutiating headaches. I found a doctor who was also a 'Qualified Disability Evaluator', and he helped me. My employer wouldn't do the ergonaumic changes required for me to continue working there so my doctor placed me on Permanent and Stationary Status after I had been back for 6 weeks. They wouldn't take his word on it though and referred me to a 'Qualified Medical Examiner'. He concurred with my doctor.

Anyway, I could go on and on. My point is, the people in your article make it look bad for the rest of us.

Good article though and thanks for letting me ramble.

Michael Harris
08-22-2003, 06:41 AM
Colleen,

You worked for a lousy company. I sat at my desk for 9-10 hours a day. When I informed my manager that I had trouble with my back and that is was a continuing problem, the company brought me a new chair - a $900 ergo chair that has about 12 different adjustments. One of the ergonomic engineers on staff with our environmental, safety, and health department came to my office to teach me how to adjust the chair to my needs. Then she helped me lay out my workspace to minimize any body strain. :) :D :cool:

Part 2: Something had happened to the cmputer system and I lost access to the double-click feature on my mouse. Since I did not have access to download the driver again, I asked fro it to be restored - nothing. Two weeks later, my right forearm started to hurt. Images of carpal tunnel syndrome raced through my mind and I went to my doctor immediately. My doctor determined that it was the beginings of tendonitis and wrote a script that said - Give him back his double-click.

I went back to the office and mentioned to the nurse (full-time nurse and half-time doctor on staff) that my arm hurt. She said that the doctor would be in the office in an hour and that I would be there at that time. I had been back in my office for only a few minutes when an ergonomic engineer showed up to help be lay out my workspace again to help with the problem. The doctor did an exam and indicated that there was no overt evidence of tendonitis, but since I was in pain something had to be done. The next day, I received an official letter indicating that my problem was not sufficient to warrant opening a Workers Comp file, but it did need resolution. They sent me to Staples (they had an account) to physically check out keyboards and pointing devices. I did a thorough hands-on evaluation of keyboards and pointing devices. I ended up with a ($110) split ergo keyboard and a ($70) wheel mouse - it is stationary and the cursor is moved with a large ball.

Now, which company would you want to work for?

I also had one other advantage - I could get up and go anywhere if I needed to. :rolleyes:

Brenda Muller
08-22-2003, 04:45 PM
Colleen, Yes unfortunately there just inconsiderate people out there and they will not learn until it happens to them...And then they say why me....The saying is "TREAT PEOPLE THE WAY YOU WANT TO BE TREATED...Things somehow or someway do come around and bite the bad people in the butt.
Brenda Muller

Corinne Pedriani--
08-22-2003, 06:54 PM
Colleen,
I'm very sorry to hear what happened to you. I hope your situation has improved.

May,
Thank you so much for the information! I had considered what negative impact fraudulent claims had in some respects, (higher insurance rates, etc.) but I had not thought about how they slow the process for the "good guys" as well.

I also agree with Leisl 100%! :) You are full of great information, and I always look forward to reading your posts! Thank you for all of your efforts, you add so much to the forums. :) :)

Michael Runner
06-08-2004, 03:51 PM
Very interesting story. :)

Victoria S Kinney
06-10-2004, 03:15 AM
Thank you May, the story was fantastic and so interesting. Also thanks for the link. Take care.

Bridgett Brown
06-10-2004, 10:28 AM
Thanks for the link. This is very interesting and informative.

Barbara Bacon -
07-05-2004, 07:17 AM
May,
Thank you for the links. The whole fraud area I find especially intriguing. My sister speaks of insurance fraud issues all the time.
I will check out these links and do some additional research into this area. I think I am leaning towards this type of work.
I can relate do to some of these stories. I have a sister who was seriously injured in a car accident. What she has gone thru to prove she is injured and cannot work has amazed me. Even after being "permanently disabled" by her orthopedic physician and obtaining social security benefits, the defending law firm says she is acting and should be able to go back to work this year. I just spent ten days taking cae of her and this is no act. The quality of her medical care is my issue, which is another story.
Thanks for listening.
Barb

Anthony L Zuluaga -
11-22-2004, 02:31 PM
May

An absolutely fabulous article you pulled up here. Anyone one in the insurance business should listen up. For many consumers who still don't have a clue why premiums go up this is why.

Cheri Beckwith -
11-24-2004, 06:34 PM
Thanks May,
This is a fantastic article. :)
I saved it as a Word document and then print it to put in my loose leaf binder. This helps me have an on going reference manual that I can refer to and carry with me. I am interested in insurance fraud and etc. this has been very helpful.
I recently applied for a position as a Claims Adjuster Trainee, but have not heard anything from them. I applied on Monday, so I am sure they have a lot of applications, but I also applied as a couple weeks ago for a part time Records Researcher (which I already do in my own business) - I realize this has nothing to do with Insurance Claims area, but wonder why I don't even get a call.
Maybe its because I have my own part time business and they don't want anyone that has somewhat of a business already established.
Any thoughts would be appreciated.
Thanks
Cheri