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Insurance  Fraud  Investigations<br />
Overview	<br />Objective<br />Definition of Fraud<br />Scope of Fraud<br />How Fraud Works<br />Working Together in:<br />...
Definition of Insurance Fraud	<br />“Any deliberate deception <br />perpetrated against or by an<br />insurance company or...
The Scope and Nature of Fraud			<br />By their very nature, fraudulent <br />claims are designed to appear<br />legitimate...
Fraud…… the “Iceberg “ Crime<br />87% of the <br />Iceberg is<br />Invisible<br />From the Surface<br />
Fraud…… the “Iceberg “ Crime<br />Only a small <br />percentage of fraud<br />is Detected. An even<br />smaller percentage...
Fraud.. The Scope<br />“33% of Property and Casualty Claims have some element(s) of Fraud.<br />Approximately 3% of Claims...
Why is Claim Fraud So Prevalent?<br />Infamous New York Bank Robber<br />Willie Sutton (1920’s) Was once<br />asked “Why d...
Why is Claim Fraud So Prevalent?<br />Infamous New York Bank Robber<br />Willie Sutton (1920’s) Was once<br />asked “Why d...
Why is Claim Fraud So Prevalent?<br />It’s PROFITABLE<br />Very little investment<br />required. <br />
Why is Claim Fraud So Prevalent?<br />It’s PROFITABLE<br />Very little investment<br />required. <br />It’s SAFE<br />Poli...
Why is Claim Fraud so Prevalent?<br />And of course,<br />
Why is Claim Fraud So Prevalent?<br />Unfortunately,<br />there’s very little<br />risk of Punishment.<br />
Why is Claim Fraud so Prevalent?<br />“Insurance Companies don’t make<br />good victims.”<br />
Why is Claim Fraud so Prevalent?<br />“Insurance Companies don’t make<br />good victims.”<br />Law Enforcement is focused ...
Why is Claim Fraud so Prevalent?<br />“Insurance Companies don’t make<br />good victims.”<br />Law Enforcement is focused ...
Why is Claim Fraud so Prevalent?<br />Insurance Companies often make<br />Claim Fraud attractive by paying<br />people to ...
The Challenges	<br />Recognition<br />Reporting<br />Analysis<br />Investigation<br />Resistance<br />
Recognition…… the biggest Challenge<br />If we only recognize blatant fraud,<br />we’re missing a lot of fraud.<br />
Without Aggressive <br />Recognition and Reporting, <br />Investigation and Resistance <br />to Fraud suffers.<br />Recogn...
When you get a reputation for<br />paying everyone that comes <br />to your door…….<br />
When you get a reputation for<br />paying everyone that comes <br />to your door…….<br />You soon have a lot of people<br ...
HOW FRAUD WORKS…	<br />Who are the fraudsters?<br />How do they think?<br />How do fraudsters  plan their frauds?<br />How...
Who are the fraudsters?<br />Anyone can commit fraud.<br />Only a small percentage of claimants/insureds are “professional...
Who are the fraudsters?<br />Fraudsters will want to appear honest and deserving…..<br />
Who are the fraudsters?<br />Their real motives may be far less virtuous…..<br />In reality, fraudsters are generally driv...
How do fraudsters think??<br />From:<br />To:<br />But, they have one thing in common..<br />
How do fraudsters think?<br />They all want <br />easy money.<br />and<br />They’re limited<br />only by their <br />imagi...
How do <br />fraudsters <br />Plan their <br />Claims??<br />
How do fraudsters plan their claims?	<br />Fraudsters learn from:<br />Prior legitimate claims<br />Other Fraudsters<br />...
How do fraudsters plan their frauds?<br />Fraudsters<br />talk to each<br />other!!<br />
How do fraudsters plan their frauds?<br />Fraudsters learn from each others’ experiences. <br />Fraudsters know the reputa...
How do fraudsters plan their frauds?<br />Insurance companies unwittingly “teach” fraudsters how to file successful fraudu...
“Backing  Into” Coverage…….<br />
“Backing into Coverage”<br />Fraudsters have the ability to control all the circumstances surrounding a fraudulent claim:<...
“Backing Into Coverage”… cont’d<br />Type of loss<br />Severity of alleged damages<br />Ability to circumvent security/saf...
“Backing into coverage”<br />Fraudsters will almost always seek to engineer each facet of the circumstances to their best ...
What are Fraudsters Counting On?<br />That their claim will appear legitimate and they will be paid.<br />That if question...
What are fraudsters counting on?<br />Even if the company denies the claim, they will have learned something which will he...
What are fraudsters counting on?<br />If prosecuted, they can flee the area.<br />If apprehended and prosecuted, they can ...
How do Fraudsters<br />Conceal their Crimes?<br />
How do fraudsters conceal their crimes?<br />Fraudsters will often change <br />their Identity and Address<br />
Background Checks <br />Uncover Aliases<br />Address Histories<br />Identify SSN’s<br />Persons Related to Claimant/Insure...
Cronin’s Law #1<br />“If you’re not who you say <br />you are, you don’t have a<br />claim!!”<br />
Alias Identification<br />Start with known identity. <br />Check databases<br />by name, SSN, & address<br />Three key ele...
Alias Identification<br />Look for overlaps<br />Vector off overlap and expand search<br />Develop new addresses, SSN’s an...
Address Histories<br />You need to know what addresses your subject has used in order to know where to look for records. <...
Address Histories cont’d<br />Once you know addresses your subject has used…<br />Determine what county these addresses ar...
Litigation Histories<br />These are very important. <br />Superior Courts:<br />Civil, Criminal, Domestic, Probate, Juveni...
Uses of Litigation Histories:<br />Confirm identities<br />Identify aliases<br />Address History<br />Financial Profile<br...
ISO  Claimsearch<br />The ISO database is one of the most powerful tools for insurance fraud investigation.<br />Millions ...
Leveraging Information<br />By uncovering aliases, felony <br />criminal histories, and undisclosed <br />tort incidents ,...
Recognizing, Reporting,<br />Analyzing, Investigating<br />and Resisting Fraud<br />
Recognizing fraud<br />This is the greatest challenge for insurance companies. <br />If they don’t recognize & report frau...
Recognizing Fraud	<br />What is the most    powerful weapon in our arsenal against fraud?<br />Is it a Cray SuperComputer?...
Recognizing Fraud<br />The most <br />effective <br />weapon in<br />recognizing <br />fraud is the <br />dedicated <br />...
Recognizing Fraud<br />What about existing automated controls in the system? Don’t they deter and detect fraud?<br />Exist...
Recognizing Fraud	<br />What are the best <br />Indicators of possible<br />Fraud?<br />
Cronin’s Law #2:<br />An active claims history is the <br />single best objective indicator <br />of probable claims fraud...
Recognizing Fraud<br />Another excellent indicator is  your intuition.<br />“I just have a bad feeling about this claim….....
Recognizing Fraud<br />You don’t have to be a fish expert to know you’ve got a dead mackerel in your drawer…<br />If it do...
Recognizing Fraud…. Indicators cont’d<br />Lack of verifiable source of income.<br />People with “real” jobs rarely are pr...
Fraud Indictors…. “Stretches”<br />“Stretches” are difficult to believe<br />fabrications created by fraudsters<br />to al...
Not every unusual circumstance<br />is indicative of fraud, but when<br />considered in the totality of a <br />claim, “st...
How do we analyze a claim <br />to determine if possible fraud<br />is present? <br />One segment at a time…….<br />The Po...
Analyzing the Claim…. Pole Vault Method<br />Each claim is <br />made up of <br />segments, like <br />short pieces of <br...
Analyzing the Claim… Pole Vault Method<br />The vaulter needs<br />a “full pole” to “clear the bar”<br />(get their claim ...
Analyzing the Claim….The Pole Vault Method<br />If any segment<br />of the “pole” is <br />weak or missing,<br />it may no...
Segments of a Claim	<br />That there is a insured/claimant who is whom he/she says they are.<br />That there was a policy ...
Segments of a claim… cont’d<br />That the loss actually occurred..<br />At the  place alleged..<br />A the time/date alleg...
Claim Segments cont’d<br />That the  object damaged was of the condition and value alleged before the loss..<br />That the...
Claim segments….. Cont’d<br />Which are of the extent and value being claimed<br />That the insured/claimant  did not caus...
Claim Segments Cont’d<br />That the insured was truthful during the application and underwriting process.<br />Regarding l...
Claim Segments…….<br />That the insured has performed all duties required in case of loss:<br />Notice to company<br />Rep...
Examining each segment of a <br />claim can help us identify <br />questionable areas and can help<br />us focus our  inve...
“Logic Path”<br />What do I know about this claim?<br />What do I suspect? (Which segments of the claim are in question?)<...
Analyzing the claim<br />Look for the LIE. <br />Focus on the segment associated with it. <br />
“Stretches” will often found to be “lies” in a fraudulent claim<br />
Stretches make the “pole’ (claim) weak.<br />
“Stretches” are <br />Exponential!<br />The more stretches there are, the weaker the “pole”/claim.<br />
The answer to your questions may already be in your file. <br />Periodic reality checks are important.<br />
Analyzing the claim<br />and the claimant…..<br />
Analyzing the claim and the claimant..<br />How much planning went into the preparation of this claim?<br />How much scrut...
Analyzing the claim and the claimant..<br />How has the insured/claimant pursued claims in the past? Litigious?<br />What ...
Analyzing the claim and the claimant...<br />Are we seeing all the players? <br />Is this a “set up” for a bad faith claim...
Investigating the Questioned Claim<br />
Planning the Investigation<br />Consider the issues which need<br />to be addressed, what information<br />is already know...
Conducting the Investigation… Tools	<br />Insured/claimant Interviews .<br />Cross-referencing and verifying data. <br /> ...
Investigation Tools cont’d<br />Use of specialized experts<br />Origin & Cause<br />Laboratory<br />Handwriting Experts<br...
Professional Affiliations<br />The most effective<br />Investigators have<br />Extensive <br />Professional<br />Contacts<...
Benefits of Using Private Investigators	<br />Knowledgeable of local area<br />Knowledgeable of state laws<br />Work close...
Subluxation!!!!<br />“Dirty Doctors” and Atty’s<br />
Private Investigators can help Adjusters be more effective in managing their workload.<br />Claim Rep<br />
Future Expectations??<br />If the…...<br />ECONOMY<br />
Partners in Claims Investigation<br />Seattle Insurance and Legal Investigations <br />(206) 992-1555    <br />www.seattle...
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Insurance Fraud Investigation By Jim Cronin, Cfe

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Insurance Fraud Investigation By Jim Cronin, Cfe

  1. 1. Insurance Fraud Investigations<br />
  2. 2. Overview <br />Objective<br />Definition of Fraud<br />Scope of Fraud<br />How Fraud Works<br />Working Together in:<br />Detection<br />Analysis<br />Investigation<br />Resistance<br />
  3. 3. Definition of Insurance Fraud <br />“Any deliberate deception <br />perpetrated against or by an<br />insurance company or agent for<br />the purpose of unwarranted<br />financial gain.”<br />Source: Coalition Against Insurance Fraud<br />
  4. 4. The Scope and Nature of Fraud <br />By their very nature, fraudulent <br />claims are designed to appear<br />legitimate.<br />
  5. 5. Fraud…… the “Iceberg “ Crime<br />87% of the <br />Iceberg is<br />Invisible<br />From the Surface<br />
  6. 6. Fraud…… the “Iceberg “ Crime<br />Only a small <br />percentage of fraud<br />is Detected. An even<br />smaller percentage <br />is Reported/Resisted<br />
  7. 7. Fraud.. The Scope<br />“33% of Property and Casualty Claims have some element(s) of Fraud.<br />Approximately 3% of Claims are Totally Fraudulent. <br />P&C Fraud costs Americans between $24 and $30 Billion each year. Approximately $200-$300 per average household.<br />Sources: Coalition Against Ins. Fraud/ Ins. Info Institute<br />
  8. 8. Why is Claim Fraud So Prevalent?<br />Infamous New York Bank Robber<br />Willie Sutton (1920’s) Was once<br />asked “Why do you rob banks?”<br />
  9. 9. Why is Claim Fraud So Prevalent?<br />Infamous New York Bank Robber<br />Willie Sutton (1920’s) Was once<br />asked “Why do you rob banks?”<br />He replied, “Because that’s where<br />the money is.”<br />
  10. 10. Why is Claim Fraud So Prevalent?<br />It’s PROFITABLE<br />Very little investment<br />required. <br />
  11. 11. Why is Claim Fraud So Prevalent?<br />It’s PROFITABLE<br />Very little investment<br />required. <br />It’s SAFE<br />Police shoot at robbers<br />and burglars...<br />
  12. 12. Why is Claim Fraud so Prevalent?<br />And of course,<br />
  13. 13. Why is Claim Fraud So Prevalent?<br />Unfortunately,<br />there’s very little<br />risk of Punishment.<br />
  14. 14. Why is Claim Fraud so Prevalent?<br />“Insurance Companies don’t make<br />good victims.”<br />
  15. 15. Why is Claim Fraud so Prevalent?<br />“Insurance Companies don’t make<br />good victims.”<br />Law Enforcement is focused on <br />crimes of violence. <br />
  16. 16. Why is Claim Fraud so Prevalent?<br />“Insurance Companies don’t make<br />good victims.”<br />Law Enforcement is focused on <br />crimes of violence. <br />If Insurance Companies don’t look <br /> out for themselves, nobody else will. <br />
  17. 17. Why is Claim Fraud so Prevalent?<br />Insurance Companies often make<br />Claim Fraud attractive by paying<br />people to “go away.”<br />
  18. 18. The Challenges <br />Recognition<br />Reporting<br />Analysis<br />Investigation<br />Resistance<br />
  19. 19. Recognition…… the biggest Challenge<br />If we only recognize blatant fraud,<br />we’re missing a lot of fraud.<br />
  20. 20. Without Aggressive <br />Recognition and Reporting, <br />Investigation and Resistance <br />to Fraud suffers.<br />Recognition….. The Biggest Challenge<br />
  21. 21. When you get a reputation for<br />paying everyone that comes <br />to your door…….<br />
  22. 22. When you get a reputation for<br />paying everyone that comes <br />to your door…….<br />You soon have a lot of people<br />coming to your door.<br />
  23. 23. HOW FRAUD WORKS… <br />Who are the fraudsters?<br />How do they think?<br />How do fraudsters plan their frauds?<br />How do fraudsters conceal their crimes?<br />What are fraudsters counting on?<br />
  24. 24. Who are the fraudsters?<br />Anyone can commit fraud.<br />Only a small percentage of claimants/insureds are “professional” crooks. <br />
  25. 25. Who are the fraudsters?<br />Fraudsters will want to appear honest and deserving…..<br />
  26. 26. Who are the fraudsters?<br />Their real motives may be far less virtuous…..<br />In reality, fraudsters are generally driven by greed and/or desperation….<br />
  27. 27. How do fraudsters think??<br />From:<br />To:<br />But, they have one thing in common..<br />
  28. 28. How do fraudsters think?<br />They all want <br />easy money.<br />and<br />They’re limited<br />only by their <br />imagination. <br />
  29. 29. How do <br />fraudsters <br />Plan their <br />Claims??<br />
  30. 30. How do fraudsters plan their claims? <br />Fraudsters learn from:<br />Prior legitimate claims<br />Other Fraudsters<br />Professional Crooks<br />Cappers<br />Dishonest Attorneys<br />Dishonest Medical Providers<br />Dishonest Body Shop Owners<br />
  31. 31. How do fraudsters plan their frauds?<br />Fraudsters<br />talk to each<br />other!!<br />
  32. 32. How do fraudsters plan their frauds?<br />Fraudsters learn from each others’ experiences. <br />Fraudsters know the reputations of different companies.<br />Professional fraudsters may even know individual adjusters’ names, reputations and authority limits. <br />
  33. 33. How do fraudsters plan their frauds?<br />Insurance companies unwittingly “teach” fraudsters how to file successful fraudulent claims.<br />Fraudsters learn all the elements of successful claims, and go to great lengths to ensure that all necessary elements are present…….. This is called……...<br />
  34. 34. “Backing Into” Coverage…….<br />
  35. 35. “Backing into Coverage”<br />Fraudsters have the ability to control all the circumstances surrounding a fraudulent claim:<br />Time<br />Place<br />Persons Present<br />Hazard<br />Notice of Hazard<br />
  36. 36. “Backing Into Coverage”… cont’d<br />Type of loss<br />Severity of alleged damages<br />Ability to circumvent security/safety controls<br />
  37. 37. “Backing into coverage”<br />Fraudsters will almost always seek to engineer each facet of the circumstances to their best advantage.<br />Fraudsters will almost always seek to maximize their damages to maximize their profit.<br />This ability to control the circumstances is both their main strength and their main weakness.<br />
  38. 38. What are Fraudsters Counting On?<br />That their claim will appear legitimate and they will be paid.<br />That if questioned, the investigation will be cursory.<br />Regardless of the outcome of the investigation, the insurance company will pay them something .. Just to go away. (“Nuisance value”).<br />
  39. 39. What are fraudsters counting on?<br />Even if the company denies the claim, they will have learned something which will help them on their “next” claim…<br />If denied, that there will be no referral to law enforcement.<br />If referred to law enforcement, that there will be no prosecution.<br />
  40. 40. What are fraudsters counting on?<br />If prosecuted, they can flee the area.<br />If apprehended and prosecuted, they can hire lawyers to “beat the rap.”<br />If convicted….the punishment will be very light. <br />
  41. 41. How do Fraudsters<br />Conceal their Crimes?<br />
  42. 42. How do fraudsters conceal their crimes?<br />Fraudsters will often change <br />their Identity and Address<br />
  43. 43. Background Checks <br />Uncover Aliases<br />Address Histories<br />Identify SSN’s<br />Persons Related to Claimant/Insured<br />Assets<br />Financial Profile<br />Litigation/Criminal History<br />
  44. 44. Cronin’s Law #1<br />“If you’re not who you say <br />you are, you don’t have a<br />claim!!”<br />
  45. 45. Alias Identification<br />Start with known identity. <br />Check databases<br />by name, SSN, & address<br />Three key elements:<br /> Parallels<br /> Disconnects<br /> Overlaps<br />
  46. 46. Alias Identification<br />Look for overlaps<br />Vector off overlap and expand search<br />Develop new addresses, SSN’s and Names<br />Cross-referencing is the key to alias identification<br />
  47. 47.
  48. 48. Address Histories<br />You need to know what addresses your subject has used in order to know where to look for records. <br />
  49. 49. Address Histories cont’d<br />Once you know addresses your subject has used…<br />Determine what county these addresses are in. <br />Remember that a city/zip code can fall into more than one county!<br />Once you know the count(ies) you know where to look for records. <br />
  50. 50. Litigation Histories<br />These are very important. <br />Superior Courts:<br />Civil, Criminal, Domestic, Probate, Juvenile, Judgment, <br />Federal Courts:<br />Bankruptcies, Civil & Criminal Filings<br />Small Claims Courts<br />
  51. 51. Uses of Litigation Histories:<br />Confirm identities<br />Identify aliases<br />Address History<br />Financial Profile<br />Character & credibility<br />Earnings Potential<br />Assets<br />Persons knowledgeable of subject<br />Prior injuries<br />Many injury suits relate to matters not found in ISO database<br />
  52. 52. ISO Claimsearch<br />The ISO database is one of the most powerful tools for insurance fraud investigation.<br />Millions of claims, searchable by name, address, SSN, telephone number, & VIN.<br />
  53. 53. Leveraging Information<br />By uncovering aliases, felony <br />criminal histories, and undisclosed <br />tort incidents , many questionable or<br />fraudulent claims will “go away”<br />or can be significantly mitigated.<br />
  54. 54. Recognizing, Reporting,<br />Analyzing, Investigating<br />and Resisting Fraud<br />
  55. 55. Recognizing fraud<br />This is the greatest challenge for insurance companies. <br />If they don’t recognize & report fraud, the rest of the claims process is moot.<br />
  56. 56. Recognizing Fraud <br />What is the most powerful weapon in our arsenal against fraud?<br />Is it a Cray SuperComputer?<br />NO!!!<br />
  57. 57. Recognizing Fraud<br />The most <br />effective <br />weapon in<br />recognizing <br />fraud is the <br />dedicated <br />claims<br />representative.<br />
  58. 58. Recognizing Fraud<br />What about existing automated controls in the system? Don’t they deter and detect fraud?<br />Existing controls catch only the “dumb” crooks.<br />Fraudsters know the system and many know how to circumvent controls. <br />
  59. 59. Recognizing Fraud <br />What are the best <br />Indicators of possible<br />Fraud?<br />
  60. 60. Cronin’s Law #2:<br />An active claims history is the <br />single best objective indicator <br />of probable claims fraud. <br />Translated: “If they’re scamming<br />you now, chances are they’ve <br />done it before.” <br />
  61. 61. Recognizing Fraud<br />Another excellent indicator is your intuition.<br />“I just have a bad feeling about this claim…..” <br />“There’s probably nothing you can do , but can you take a look at this claim……”<br />“ I can’t put my finger on it, but there’s something that’s not right here…”<br />
  62. 62. Recognizing Fraud<br />You don’t have to be a fish expert to know you’ve got a dead mackerel in your drawer…<br />If it doesn’t pass the “smell test,” There’s probably something fishy going on…<br />
  63. 63. Recognizing Fraud…. Indicators cont’d<br />Lack of verifiable source of income.<br />People with “real” jobs rarely are professional claimants. <br />Overly knowledgeable of insurance.<br />“Stretches of the imagination.”<br />
  64. 64. Fraud Indictors…. “Stretches”<br />“Stretches” are difficult to believe<br />fabrications created by fraudsters<br />to allow them to “Back Into<br />Coverage” by tailoring their <br />version of the events surrounding<br />the alleged loss to best serve their<br />interests.<br />
  65. 65. Not every unusual circumstance<br />is indicative of fraud, but when<br />considered in the totality of a <br />claim, “stretches” can help<br />alert us to questionable claims.<br />Fraud Recognition….”Stretches”<br />
  66. 66. How do we analyze a claim <br />to determine if possible fraud<br />is present? <br />One segment at a time…….<br />The Pole Vault Method<br />
  67. 67. Analyzing the Claim…. Pole Vault Method<br />Each claim is <br />made up of <br />segments, like <br />short pieces of <br />the pole. <br />
  68. 68. Analyzing the Claim… Pole Vault Method<br />The vaulter needs<br />a “full pole” to “clear the bar”<br />(get their claim <br />paid.)<br />
  69. 69. Analyzing the Claim….The Pole Vault Method<br />If any segment<br />of the “pole” is <br />weak or missing,<br />it may not be <br />possible to clear<br />the “bar.”<br />
  70. 70. Segments of a Claim <br />That there is a insured/claimant who is whom he/she says they are.<br />That there was a policy of insurance in effect…<br />at the time of the loss.<br />
  71. 71. Segments of a claim… cont’d<br />That the loss actually occurred..<br />At the place alleged..<br />A the time/date alleged..<br />In the manner alleged..<br />That the loss was a covered peril.<br />
  72. 72. Claim Segments cont’d<br />That the object damaged was of the condition and value alleged before the loss..<br />That there were damages…<br />which were caused by the occurrence<br />
  73. 73. Claim segments….. Cont’d<br />Which are of the extent and value being claimed<br />That the insured/claimant did not cause the loss.<br />That the insured/claimant have been truthful regarding the loss..<br />
  74. 74. Claim Segments Cont’d<br />That the insured was truthful during the application and underwriting process.<br />Regarding loss history, value/condition and ownership of property<br />
  75. 75. Claim Segments…….<br />That the insured has performed all duties required in case of loss:<br />Notice to company<br />Report to police<br />Cooperation<br />Mitigate Damages<br />Examination under Oath<br />Proof of Loss<br />
  76. 76. Examining each segment of a <br />claim can help us identify <br />questionable areas and can help<br />us focus our investigations. <br />The “logic path” will help us<br />further focus our investigation.<br />
  77. 77. “Logic Path”<br />What do I know about this claim?<br />What do I suspect? (Which segments of the claim are in question?)<br />What issue(s) am I trying to resolve?<br />What information would help resolve the issue(s) in question?<br />Where can I get this information? <br />
  78. 78. Analyzing the claim<br />Look for the LIE. <br />Focus on the segment associated with it. <br />
  79. 79. “Stretches” will often found to be “lies” in a fraudulent claim<br />
  80. 80. Stretches make the “pole’ (claim) weak.<br />
  81. 81. “Stretches” are <br />Exponential!<br />The more stretches there are, the weaker the “pole”/claim.<br />
  82. 82. The answer to your questions may already be in your file. <br />Periodic reality checks are important.<br />
  83. 83. Analyzing the claim<br />and the claimant…..<br />
  84. 84. Analyzing the claim and the claimant..<br />How much planning went into the preparation of this claim?<br />How much scrutiny did the insured/claimant expect this claim to receive?<br />How much scrutiny is the insured/claimant prepared to withstand?<br />
  85. 85. Analyzing the claim and the claimant..<br />How has the insured/claimant pursued claims in the past? Litigious?<br />What motivated the insured/claimant to make the claim? <br />Desperation?<br />Greed?<br />Legitimate claim? <br />Build-Up?<br />
  86. 86. Analyzing the claim and the claimant...<br />Are we seeing all the players? <br />Is this a “set up” for a bad faith claim?<br />
  87. 87. Investigating the Questioned Claim<br />
  88. 88. Planning the Investigation<br />Consider the issues which need<br />to be addressed, what information<br />is already known, and the tools<br />available to find needed info.<br />Each “tool” in our toolbox <br />is different. Know what tools are<br />available, how to use them, and<br />which ones to use when.<br />
  89. 89. Conducting the Investigation… Tools <br />Insured/claimant Interviews .<br />Cross-referencing and verifying data. <br /> Examinations under oath.<br />Scene investigations.<br />Witness interviews.<br />Public records checks<br />Database checks<br />Claims histories.<br /> Surveillance<br />Neighborhood Canvasses<br />
  90. 90. Investigation Tools cont’d<br />Use of specialized experts<br />Origin & Cause<br />Laboratory<br />Handwriting Experts<br />Accountants<br />Medical Experts<br />Legal coordination<br />Professional contacts.<br />
  91. 91. Professional Affiliations<br />The most effective<br />Investigators have<br />Extensive <br />Professional<br />Contacts<br />
  92. 92. Benefits of Using Private Investigators <br />Knowledgeable of local area<br />Knowledgeable of state laws<br />Work closely with defense counsel<br />Face to Face contact<br />Special expertise in interviewing<br />Special expertise in fraud investigation.<br />Cognizant of good faith, coverage, liability issues.<br />
  93. 93. Subluxation!!!!<br />“Dirty Doctors” and Atty’s<br />
  94. 94. Private Investigators can help Adjusters be more effective in managing their workload.<br />Claim Rep<br />
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