There are so many different aspects to insurance fraud. Besides fraudulent claims and falsely-acquired settlements, money may be a motivator for other types of insurance fraud.
Take, for example the case of a man who lost his job. He had a wife and three children and suddenly found it impossible to find employment. He was desperate so he faked a slip and fall accident at the local mall. He claimed his slip and fall injuries were significant enough to prevent him from working and because it is difficult to prove or disprove soft tissue injuries, the insurance company was reluctant to settle quickly. His situation grew direr because now he was unable to even look for a job because it would show he was faking injuries.
The claims adjuster held the case open and unresolved for almost two years. The claimant began seeing a doctor and started a 6-month period of filling prescriptions for strong pain killers – a lot of them. The adjuster wasn’t seeing any improvement in the claimant’s condition, nor any deterioration from so many medications.
An investigator was called in to answer the two questions always at the center of slip and fall injury investigations – and most fraudulent insurance claims:
- Is the claimant working elsewhere?
- What is the level of activity in which the claimant lives his daily life?
Videotape evidence taken during the slip and fall fraud investigation proved the claimant was not working elsewhere at any time or for any money. However, he was engaged in selling the painkillers on the street, pulling in the street value for the pills.
He had indeed found a way to provide some support for his family. Because he was engaged in illegal activity, the information uncovered during the slip and fall investigation and the evidence to support it had to be turned over to the authorities, with the knowledge and consent of the client.
What began as a ruse to generate some income for his family ended up in charges for drug trafficking. In the end, the insurance company did not pay any benefits to the man at all. However, they still had the costs to process the case including the IME, adjustor and investigators’ costs.
Insurance fraud costs – from beginning to end – whether or not the claimant has the claim denied, it still costs.
-T. Wilcox, CEO, International Investigators