Insurance Fraud Investigators

Many years of experience working for major insurance companies – top results

Fraud or conspiracy to de-fraud is considered by most persons to be soft crimes. This is because it is not hurting anyone except the insurance company. This is the perception that too many people have and explains why so many law abiding people commit insurance fraud. To prove these charges is a complex and difficult job, and often people are caught because of minor mistakes which they make.

One of the challengers for insurers is to maintain the application of rigor in assessing what material or relevance to a decision that there may have been fraudulent conduct on the part of the claimant, or there are substantial issues of fact in dispute.

The system works more expeditiously if the parties concentrate on material issues and supply all relevant information at the earliest opportunity. The best evidence is usually obtained by focusing on the issues and prompt investigation when events are fresh in the mind of witnesses. Time later spent gathering and reconsidering further information unnecessarily consumes resources. Do not procrastinate assess the claim and get it out to an investigator if necessary.

The insurer relies to a great extent on timely action and the record keeping of their direct staff, the ability of their assessors to keep abreast of current technology, and the competence of the investigators to who they contract out work.

The best definition of fraud is “TO OBTAIN A BENEFIT BY DECEPTION”.

I was very lucky to be a member of the WA Police Force in an era where I worked with exceptionally bright and dedicated Detectives. That experience has been the back bone of the success as a Detective and my venture into the Private Investigation Industry.

It is my view from experience that not every policeman or private investigator has the ability to be a good investigator. To work for me the person must be a mature ex WA Detective who has been through the Detective Training School, highly skilled, with a solid background of being “hands on”, and an unblemished record.

CLAIMS STAFF

I understand that most claims are reported to your Agents throughout Australia and it very important that they write down what the claimant is alleging what occurred. In the twenty one years I have been investigating claims for Insurance Companies I have impressed upon the agents I have met that they must always keep a quotes and notes book that they can write down exactly what the claimant tells them.

A claims officer will also be put in the position where the insured will telephone to report a claim or to see how their claim is going. It is important that you develop skills where you can record any inconsistencies and write them down and report them to your supervisor. Do not try and interrogate the insured on the telephone leave it to a skilled investigator.

I can tell you now that an investigator only has one real shot at interrogating a suspect. If there appears to be an inconsistency don’t question the insured write it down and make sure that the information is handed to the investigator.

Develop your own skill in getting information from the insured.

Most persons who telephone in a claim are normally visibly upset or feel violated the fact their home or car etc has been stolen or damaged. Use your skills as an interviewer.

What I would say or something to the effect using your best friendly voice “I am really sorry that has occurred you must feel terrible. What can I do to help you?” By saying this you are going to get the confidence of the person on the other end of the line, and keeping the same tone of voice, it is then easy to extract other information from them.

IT IS VERY IMPORTANT FOR YOU TO WRITE DOWN EXACTLY WHAT THEY SAY AS IT MAY BE INCONSISTANT WITH WHAT THEY HAVE TOLD THE AGENT OR THE POLICE. THIS INFORMATION IS A GOOD TOOL FOR YOUR EXTERNAL  INVESTIGATOR COULD BE USED AS EVIDENCE AT A LATER DATE.

IMPORTANCE IN MAKING A QUICK DECISION TO APPOINT AN INVESTIGATOR

It is very important to appoint an investigator as soon as possible. If you are unsure whether to have it investigated it is only a phone call away to get my advice. That initial phone call is free. If the claim is fraudulent a delay will give the client a better chance of fabricating theft.

The majority of Insurance claims are based in the metropolitan and country areas and to investigate a claim can mean substantial costs. I will not burn insurance companies money and am very conscious of any investigation expenditure.

You need to make sure the investigator does not do unnecessary work. You must give the investigator reasonable precise instructions regarding the scope of his inquiries. Never simply ask him to “Investigate this claim”, because this will give an unscrupulous investigator the opportunity to milk the claim for every last cent.

As many of my clients know, it is my practice to contact the Claims Consultant immediately I reach the conclusion that the claim is legitimate and/or that further inquiries will achieve nothing. I don’t get any satisfaction in doing work that is a waste of my time and their money.

A good investigator should be able to make an assessment on whether the claim should have an in depth investigation by reading the documentation and just making a few telephone calls, that is why if you are uncertain about the claim just shoot it across for an assessment.

Insurance companies should therefore impress upon the investigator the importance of contacting them when they reach the stage where they believe further inquiries are fruitless – either because they are satisfied the claim is genuine or because they see no prospects of obtaining evidence that shows the claim is fraudulent. If you agree it means you will be paying the claim so cut your losses, instruct the investigator to terminate his inquiry.

DON’T BE CAUGHT OUT

I have seen it on many occasions in the past where I have been asked to do an investigation where another firm of investigators has completed an investigation with a conclusion “Decline this claim as it is a fraudulent or suspicious”. They have made this statement without any evidence whatsoever. Sometimes it is very frustrating because there has been a fraud flag raised but having completed your investigations and there is no evidence, you can’t decline a claim on suspicion.

REMOTE AREAS

As you are aware geographically Western Australia is large and has many remote areas.

There are no investigation companies domiciled outside the metropolitan (none that I could recommend) area so travelling to some of these areas can be cost prohibitive. This does not mean worthwhile inquiries cannot be made.

I have a net work of information centre’s I have established over the years in country areas of WA, the Pilbara and Kimberley areas. One thing I always do is make regular contact with these persons either to get information or just keep in touch.

I can make calls to most police stations and get the response necessary to complete an inquiry and never ask for information I am not entitled to get. I have been doing this for twenty years and even though policeman change positions I am well known through the Police Service.

I did one recently where a group of people had been at a hotel in Kununurra and the vehicle was stolen and the circumstances suggested that alcohol may have been a factor. I telephoned the insured and he did not know if any offender had been caught. I then telephoned the police station in Kununurra and ascertained from a police officer that juvenile offenders had been apprehended and dealt with.

FRAUD “NEW POLICIES”

There are many reasons for this type of fraud, however the main reason is the vehicle/home/contents were not insured when loss/damage occurred.

This type of fraud mainly occurs with:

  1. Theft of vehicles
  2. Home damage
  3. Motor vehicle accidents
  4. 4 Burglaries

For example, a person’s vehicle is stolen or involved in an accident, or their home is damaged or burglaries and they were not covered by insurance at the time the damage occurred.

This type of offender will usually take out cover then wait around for a period of time ranging from 1 week to three months before making the claim for the loss or damage sustained.

If a police report is required, generally it is not reported until after the cover or policy has been obtained, although it has been known for less diligent people to make a correct report and lodge a false claim.

This type of fraud is usually an act of desperation as a person can only see their loss and not the consequences that will follow if caught; therefore professional insurance defrauders avoid it.

It is most important that qualified personnel vet these claims.

Various successful investigations strategies are:

FRAUD INDICATORS

  1. Policy in the first year.
  2. Policy holder has little or NCB.
  3. Vehicle over insured.
  4. PH is evasive and/or nervous.
  5. PH demands immediate settlement of claim.
  6. Vehicle registration due to expire.
  7. Insurance Policy due to expire.
  8. PH has long claims history.
  9. PH has history of consistently changing insurers.
  10. PH is unemployed.
  11. PH does not have a stable background. Lives in a caravan.
  12. Supplying false documentation.
  13. PH removing themselves from the incident
  14. Date reported more than 60 days after date of loss.
  15. Date reported after expiry date of policy.
  16. Incurred greater than $10,000.00-Burglary, theft, vandalism.
  17. Date of loss within 30 days of Risk attachment date.
  18. Date of loss within 30 days of inception date.
  19. Date of loss is lodged after expiry date of the policy.
  20. Single vehicle accident between 10pm and 5am Monday to Friday.
  21. Single vehicle accident between 6pm Friday and 5am Monday.
  22. Motor vehicle theft, not recovered.

ARSON

Arson is the crime of deliberately setting fire to a property. It is a major crime and more often than not, the person/s was facing major financial hardship.

It is important to have an investigator at the scene as soon as possible to flood the area to see if there are any witnesses.

An example of having an investigator on the scene is a shop that burnt down in Fitzgerald Street North Perth. House to house inquiries revealed a witness that had taken photographs not long after the fire started. One of the photographs showed a rear door burning with the security bar still in place across the door inside the shop. The front door was still intact and locked. With other evidence the owner was charged and convicted of Criminal Damage by Fire.