Courts routinely hold that a public adjuster’s fraud is the policyholder’s fraud, even when done without the policyholder’s knowledge. When a public adjuster or lawyer takes over the claim presentation for the policyholder, and supplies false or inflated claim information, there may be sufficient grounds to void the policy or enforce a misrepresentation or concealment policy exclusion.
The focus on fraud investigations typically is whether the policyholder has misrepresented or concealed a material fact in connection with the claim presentation. Read article.
by Gene Weisberg | September 2019
Photos form the backbone of billions of dollars in claims. Yet photos can be so easily and convincingly altered that insurers are having difficulty uncovering the deceit hidden in the altered metadata embedded in images used for claims and underwriting.
Forgeries are subjecting insurers to a growing risk of losses from well-doctored images, especially for auto claims. The potential to use readily available technology to slip altered images past insurers has grown exponentially in recent years. Fraudsters thus are increasingly targeting insurers with doctored images to support their crimes. Read article.
by DAN GUMPRIGHT | August 2019
So warns the Coalition Against Insurance Fraud in a contentious civil suit with national implications for all fraud fighters. At stake is whether fraud fighters can be personally sued for bad faith in Washington state — and ultimately around the U.S.
The fraud fight itself could be diminished if the the lower-court ruling stands, and migrates to become court precedent or law in other states. Fraud fighters may well approve dubious insurance claims to avoid the personal threat of life-altering bad-faith suits. Scams thus would accelerate wherever this decision holds sway, the Coalition cautions. Honest consumers would pay a parallel price in higher premiums. Read article.
by MATTHEW SMITH, Esq. | April 2019
New York’s photo-inspection law (Section 3411 NYIL and Regulation 79 (11NYCRR67)) took effect Dec. 1, 1977. The law is now 41 years old. It is apparent to me that there are misconceptions about why the law was enacted. There also is some debate today on whether the law is cost-effective.
Many have called me the “Father” of the photo-inspection law. So I have decided to lay out the law’s history, and answer whether it is needed today. Read article.
by JOHN REIERSEN, CPCU, CFE, CIE | March 2019
The year 1977 was a watershed for automobile insurers, consumers and fraudsters alike in New York. Auto-insurance scams and thefts reached record numbers. Insurers suffered significant fraud losses as a result. Auto premiums shot upward, making insurance less-affordable for honest drivers and their families.
Outcry for action grew, both among consumers and the insurance industry. The results were anti-fraud reforms intended to tamp down wide-ranging schemes. Key was a bellwether regulation requiring auto insurers to physically inspect and photograph a small but heavily fraud-prone segment of used cars before they could be insured.
Photo inspections still are effectively catching auto fraudsters throughout New York today. Yet a brewing insurer effort to water down photo inspections is afoot. This could set back decades of successful defense against vehicle scams. Auto premiums for New York drivers also could rise. Read article.
by WILLIAM PAGAN | February 2019
“The public’s safety is your top concern, right?” the plaintiff’s counsel asks your star witness in a dubious slip-and-fall lawsuit against your organization.
“Yes,” your witness replies.
Congratulations. You’re well on your way to losing a multi-million-dollar suit by falling into a trap guided by a spreading civil-litigation tactic called Reptile Theory. This tactic often supports suits seeking to legitimize fraudulent and inflated insurance claims.
Reptile attacks are increasingly deployed by plaintiffs in civil cases against insurers and other large organizations. The goal is to twist a case away from the facts and evidence. Juries are manipulated into deciding cases on raw emotions instead of the evidence and rule of law. Read article.
by LAURA MCADAMS | January 2019
Insurers are looking for new ways to differentiate from competitors in a property and casualty industry where the margin of error grows increasingly miniscule. Especially, insurers are focusing on improving customer experience, including streamlining processing at the point of claim. This is the much-vaunted low-touch or touchless policy and claim lifecycle.
Fraudsters are eager to exploit these opportunities as insurers scramble to install streamlined new technology. Indeed, low-touch claims with faster payments are attractive for just about everybody: insurer, consumer and fraudster. Read article.
by DAN GUMPRIGHT | October 2018
As technology grows more-advanced and affordable, insurance companies are deploying increasingly effective tools to combat fraud. Telematics, wearables and a host of other tools that comprise the Internet of Things are being more widely adopted. Machine learning, artificial intelligence and predictive analysis improve fraud detection by helping make sense of the vast influx of IoT data.
And now comes blockchain. This advanced tool offers yet more potential to transform the insurance industry — and fraud fighting with it. Insurance transactions such as claims and policy applications are more secure and transparent when conducted via blockchain. Read article.
by DANIEL MARVIN & ROBERTO ALONSO | August 2018
A crime wave of fake health plans risks a sorry repeat if a proposal to authorize so-called Association Health Plans is adopted in its current format. Ambiguities in whether states would play a fully empowered role in overseeing today’s Association Health Plans leave open a trap door of vulnerability to schemers.
More than 200,000 Americans were defrauded by operators of phony health plans in 2002-2004, leaving many with ruinous medical bills and sagging finances. Bogus plans swept across the U.S. like germ warfare. A steady flow of defrauded health-insurance buyers incited national headlines back in 2002-2004. State and federal regulators finally crashed the party and shut down the schemes in concert with federal crackdown. Read article.
by MATTHEW SMITH, Esq. | May 2018
Fraud is a unique crime with many distinctive features. Its complexity is worthy of deep exploration; its high costs require this effort. Yet there is limited research to assist with preventative strategies. At the core is the lack of research on the psychology of insurance fraudsters: knowing what motivates — and de-motivates — them to commit this crime.
Psychological research hones in, with more precision, on the core reasons criminals behave in deviant ways. Understanding this is key to developing anti-fraud strategies that focus directly on the problem’s nucleus — the fraudster’s mind and motivations. Read article.
by J. MICHAEL SKIBA, MBA, PhD | March 2018
A workers-compensation insurer’s audit reveals that the 10-person clerical business the insurer thought it covered actually is a 100-person window-washing firm, specializing in high-rise buildings. That can be dangerous work, high up on the scaffolding. The employer illegally paid minimal workers-compensation premiums by misclassifying its business and lowballing the number of employees. The owner might have paid tens of thousands of dollars more in premiums a year if he’d told his workers-compensation insurer the truth.
Premium fraud in workers compensation has long bedeviled insurers. The growing willingness of insurers and prosecutors to combat these expensive schemes is something new and welcome. The question is what are an insurer’s remedies? The answer involves traditional approaches along with newer ones — some that are untried though promising. Read article.
by DENNIS B. KASS | January 2018
A pronounced fraud and abuse trend in recent years involves fabricated and often useless tests to diagnose the health of muscles and nerve cells that control them.
These tests can help diagnose radiculopathy and other nerve injuries in vehicle crash victims. Dishonest practitioners also can easily manipulate the tests, creating a gateway to expensive insurance scams. While medically helpful, these tests track with a larger national trend of extensive fraud in the diverse field of diagnostic tests. This is especially true for automobile and workers compensation. Read article.
by Dr. JOHN E. ROBINTON | October 2017
A concerning trend in claims management and civil litigation that will have a major impact on insurance fraud is the emergence of “investments” in personal-injury litigation by third-party lenders. Traditionally, personal-injury attorneys finance suits from their own pocket. That includes costs of taking a personal-injury civil matter to trial. Filing fees, process servers, stenographers and expert fees are a risk borne by the plaintiff’s attorney. Read article.
by ADAM BRAND & JAMES CRAIG | August 2017
Special Investigation Units (SIUs) are key components of any healthy insurance company because of their ability to recognize and fight fraud. However, these units often operate today more or less on their own, separate from the general claims function within insurance enterprises. Read article.
by KEITH DALY | July 2017
Privacy being redefined by vast information fraud fighters can access from connected devices, others sources. Fraud fighters must set fair privacy standards to avoid policymakers imposing standards on them. Read article.
by MATTHEW SMITH, Esq. | May 2017
Scammers evolve tactics for medical equipment, sham clinics, nerve tests
Nimble scammers are evolving tactics to overbill insurers for expensive durable medical equipment and compound creams — and launder ill-gotten profits. Insurers are stepping up the pressure with affirmative civil and criminal actions. Read article.
by ROBERT A. STERN & JAMES A. MCKENNEY | April 2017
Fraud fighters perceive fewer scams; yet organized rings seen growing. Recommendations include closer cooperation between insurers and law enforcement. Read article.
by DENNIS JAY | April 2017
Anti-fraud tech is growing faster than anyone can fully predict their impact. Forward-thinking insurers are embracing options such as Internet of Things, mobile phones, metadata, geolocation and digital footprints. Read article.
by DAN DRAZ | April 2017
A troubling trend of construction firms illegally hiding workers in shell companies to avoid paying state-required workers-compensation coverage began emerging in Florida in the early 2000s.
Historically, dishonest contractors lowballed large amounts of their payroll, undetected. The goal was to under-report employees and salaries, and lie that employees worked safer jobs than they really did. Read article.
by DAVID M. BORUM, CIFI, CFI, CIFI | October 2016
Older myths crumbling under weight of newer arson science
Dramatic legal changes will affect every fire investigator and arson case, and thus every insurer involved in fire-claims litigation. Investigators wishing to justify conclusions from the process of elimination must carefully document all hypotheses considered and ruled out. Read article.
by GEORGE A. CODDING | October 2016
In the cards: Anti-fraud tech tilts odds toward insurers, spurs claimant satisfaction
As technology transforms data into shared intelligence, claims will be validated more promptly. Increased transparency will eliminate much of the unknown. Decision-making and claim transparency also will reduce a claimant’s opportunity and inclination to defraud. Read article.
by THOMAS MULEY | September 2016
Compounded pain creams compound scams with fraudulent pricing, kickbacks
Automobile and workers-compensation insurers are the primary targets of scams involving expensive compounded pain creams. Prices are extremely high, yet there is little evidence the creams work. Doctors can make up to $10,000 monthly by prescribing compounded creams, which patients often don’t need. Read article
Enhanced data-sharing uncovers workers-comp misclassifying schemes in N.C.
Employer misclassification of workers leaves injured workers without medical care, and creates an unfair competitive playing field. State agencies in North Carolina are sharing data that is critical to pursuing businesses that illegally misclassify workers. Read article
Did life-insurance murderer target sister-in-law as next victim?
Harold Henthorn received life in prison for pushing his wife Toni Bertolet off a cliff for $4.6 million of life-insurance money. In a first-person story, the sister-in -law of his first wife chillingly believes Henthorn also targeted her for murder. Read article.
Zeroing in on zero tolerance in combatting insurance fraud
Values are the bedrock of any insurance company. Zero tolerance for fraud is a key value. Leaders must create an effective anti-fraud program. That includes a company-wide culture of zero tolerance involving all employees. Read article
Courts broadly view fraud laws to bolster crime fighting
Fraud is a serious crime that requires broad interpretations of statutes to effectively fight this crime, several recent court rulings suggest. Dishonest clinics, staged crashes and state-insurer ties recently were scrutinized. Several decision support the Coalition’s policy of urging of courts to broadly construe laws. Read article
TrendWatch: New developments about fraud in America
Mobile phones and wearables are emerging anti-fraud battlegrounds. … New York’s Supreme Court will review Facebook’s efforts to block access to accounts in a disability-fraud probe. … A state agency is ramping up anti-fraud messages. The umbrella name: “Idiots, liars and losers.” Read article.