Red Flags of Insurance Fraud

Red Flags of Insurance Fraud

Worker’s Compensation Premium Fraud – occurs when an employer provides false information in order to obtain a lower insurance rating.

Red Flags:

• The employee’s injuries are not consistent with the employee’s job classification or the nature of the business.
• The employee states that his/her employer is other than what is listed on the claim form.
• The employee disputes information supplied by the employer on the first report of injury.
• The employee disputes the average weekly wage due additional income (i.e., cash, per diem, and/or 1099 income).
• There are cross-outs and erasures on the injury forms.
• The employer refuses to cooperate in the claims investigation; refuses to provide employee with claim form.
• Employer’s witnesses to the accident are generally management personnel.
• The employer is routinely cited for safety violations.
• Employer paying medical bills and not reporting injuries.

Worker’s Compensation Fraud – occurs when an employee files an inflated or false injury claim in order to receive benefits or increase benefits.

Red Flags:

• Employee is disgruntled, soon-to-retire, or facing imminent firing or layoff.
• Employee takes more time off than the claimed injury seems to warrant.
• Employee is new on the job.
• Employee is experiencing financial difficulties and/or domestic problems prior to submission of claim.
• Employee is unusually familiar with workers’ compensation claim handling procedures and laws.
• Employee has several other family members also receiving workers’ compensation benefits or other “social insurance” benefits, i.e. unemployment.
• Surveillance or “tip” indicates that the totally disabled worker is currently employed elsewhere.
• Employee comes to office for delivery of benefit checks, avoids use of US Mail.
• Employee cancels or fails to keep appointment, or refuses a diagnostic procedure to confirm an injury.
• Social Security number provided does not belong to employee.
• Employee refuses or cannot produce solid or correct identification.

Staged Accident Fraud – occurs when a person intentionally causes or is involved in an accident, or walks in and reports an accident in order to receive compensation for false or intentional damages and injuries.

Red Flags:

• Claimant has prior accidents of similar circumstances.
• Claimant has multiple past claims with same attorney.
• Claimant is unemployed.
• Lack of familiar or personal relationships between occupants of claimant vehicle.
• Inconsistencies in multiple claimants’ versions of seating in vehicle, why claimants were in vehicle, and destination of claimants.
• Claimant demonstrates familiarity with claims process and claim evaluation.
• Presence of an overly enthusiastic witness at the accident scene.
• Claimant has recently purchased vehicle, and/or insurance.
• Victim is usually female or elderly.

Property Fraud – the falsification or inflation of a claim for the loss of personal property in order to obtain a larger settlement.

Red Flags:

• Insured is overly pushy for a quick settlement.
• Insured handles all business in person, thus avoiding the use of the mail.
• Losses are incompatible with insured’s resident, occupation and/or income.
• Losses include a large amount of cash.
• Insured is willing to accept an inordinately small settlement rather than document all claims losses.
• Buildings and/or contents were up for sale at the time of the loss.
• Suspiciously coincidental absence of family pet at the time of fire.
• Building and/or business was recently purchased.
• Building is in deteriorating condition and/or lacks proper maintenance.
• Fire scene investigation reveals absence of items of sentimental value; e.g. family Bible, family photos, trophies.
• No police report or an over-the-counter report in situations where police would normally investigate.
• Insured’s loss inventory differs significantly from police department’s crime report.

Disaster Fraud – occurs in the aftermath of a disaster when the insured claims false or inflated claims on intentionally caused or pre-existing damage.

Red Flags:

• Insured declares extensive losses without physical evidence, photographs or documented receipts.
• Items claimed to not match claimant’s lifestyle, decor, house, occupation or income.
• Lack of carpet indentation from alleged large furniture or appliances.
• Insured is overly pushy for quick settlement.
• Investigation reveals absence of family photographs, heirlooms or items of sentimental value.
• Affected area was not evacuated.
• No other homes were damaged or destroyed in the affected area.
• Insured claims items were new.
• Insured can’t properly describe items as to function or features.
• Insured property was not located in major damaged area.
• Property was in poor condition prior to loss.
• Insured cannot produce damaged item(s) for viewing.
• Insured claims unrepaired damage from a previous disaster.

Securities / Promissory Notes Fraud – the marketing and selling of investment opportunities that do not qualify with the regulations set forth by or have not been registered with the Office of Financial Institutions.

Red Flags:

• Unbelievable interest rate offered on investment. If it seems “to good to be true”. . . it probably is.
• An agent or other representative urges you to pay with cash.
• A salesperson urges you to cash in your certificates of deposit (despite the interest penalty) and put the money into investments, annuities, or life insurance policies.

Vehicle Theft Fraud – occurs when the owner of a vehicle disposes of or fraudulently reports their vehicle stolen in an attempt secure a settlement.

Red Flags:

• Insured has lived at current address less than six months, or been with current employer less than six months.
• Insured does not have a telephone or is difficult to contact.
• Insured is unemployed.
• Insured claims expensive contents in vehicle at the time of theft.
• Insured is behind in loan payments on vehicle and/or other financial obligations.
• Insured has a previous history of vehicle theft claims.
• Vehicle was recently purchased.
• Vehicle has a history of mechanical problems or is a “gas guzzler”.
• Vehicle has incorrect VIN, or VIN is different than VIN appearing on the title.
• Vehicle is recovered with seized engine or blown transmission.
• Vehicle is recovered stripped, burned, or has severe collision damage within a short duration of the time after loss allegedly occurred.
• Loss occurs within one month of issue or expiration of the policy.
• Coverage was obtained via walk-in business to agent.
• Coverage is for minimum liability with full comprehensive coverage on late model and/or expensive vehicle.
• Police report has not been made by insured or has been delayed.
• License plate does not match vehicle and/or is not registered to insured.
• Salvage yard or repair garage takes unusual interest in claim.

Tell Tale Signs of a Cheating Spouse

The following is a guide to help you determine if your mate is cheating on you. After reading this list you may find there is some area of concern. Do not confront the cheater. This will only cause them to clean up their act and make it more difficult for you to catch them. You may not have enough proof to make your case. I would urge you to seek professional help.

* At the beginning of an affair the mate that is cheating is more attentive to his spouse. This is due to guilt that the cheater may be feeling at the time.

* After the affair has been going on for a while the person cheating seems to find fault with the person he/she may be living with to try to justify the affair in their mind.

 

* Cheating spouses may lose attention in the activities in the home. They don’t show interest in the livelihood of you or the children that live in the home. Nor do they have any desires to do any fix-ups to the home (i.e. lawn care, house repairs, etc…..)

 

* Intuition (gut feeling) that something is not right usually is a sign you may have a cheating problem “when in doubt check them out”.

 

* Cheaters may have a change in sex life (i.e. more sex, less sex) as well as unexplained sexual requests.

 

* The cheater has a definite change in attitude towards everyone in the home, especially the mate (i.e. if he/she didn’t act the way they do, well then maybe I wouldn’t be doing the things I do).

 

* Another sign is “Finances”. “If someone wants to play they have to pay” therefore keeping an eye on their monies (i.e. check stubs, bank account balances, credit card bills, etc…) would tell you whether their spending more money than usual.

 

* Grooming habits will change. Cheaters will be more attentive to their person (e.i. the way they dress, frequent bathing, physical fitness, grooming of their hair, switching of colognes, etc…).

 

* Physical signs to look for to determine whether or not someone is having an affair is lipstick on the collar, odors of cologne/perfume on a shirt/blouse, checking underwear for secretion stains. You can also check their wallets and/or the glove compartments of their car to see if they left receipts, pieces of paper with phone numbers, addresses, condoms, etc.

 

* You may want to monitor your spouse for two weeks. During this time keep track of the mileage on their car. Monitor the time they leave for work and the time they come home. Keep a calendar and note the times, this should help you establish a pattern. If your mate claims to be working late, check paycheck stubs to verify this overtime.

 

* Be tuned in to home telephone calls when your mate has a tendency to whisper or gives a quick answer and immediately hangs up or when you answer the telephone and get an abrupt hang up.

 

* Many cheaters use cellular telephones to communicate with their lovers. Should your mate have a cellular telephone you may want to get a detailed billing of the calls made from the cellular phone to determine whether a certain number has been frequently called. A good area to start looking is for the first number called when your mate first leaves for work and the same number called again right before they return home.

 

* Female cheaters are more discreet in the selection of a lover . This is most likely because of their concern of Sexually Transmitted Disease’s (STD’s). Most females are looking for a longer lasting relationship rather than a “one night stand”. In past years men were the aggressors, in society today, with the increase of women in the work force, women have become equally aggressive.

 

* When a female is having an affair she tends to have more of a “glow” about her.

Tips for Testifying in Court

1. Listen to the question. Make certain you understand the question. If you do not understand the question, ask the attorney to repeat the question.
2. Repeat the question in your head.
3. Answer the question with the shortest answer consistent with the truth, and shut up.
4. Do not volunteer information.
5. Do not get angry.
6. Answer the question truthfully, even if the answer hurts you.
7. Watch out for the compound question.
8. Watch out for the question that assumes facts that are not true.
9. Watch out for questions that give a wrongful summation of the facts.
10. Do not characterize your testimony.
11. Try to avoid using absolute words, like “no”, “never”, and “all”.
12. Avoid getting boxed in with “everything you remember”, or “everything you know”.