If you are self-insured and dealing with an insurance claim, this article will help you learn about the claim investigation process, and what to look for in retaining the services of an investigator. It also contains helpful information for those who have experience handling claims but need to learn more to better protect their business from fraud. In addition, it’s helpful for those who pay premiums but want to understand how the insurance companies investigate claims.
first, look into the background of the claimant
It is considered best practice to search for red flags first to determine the likelihood that their claim is fraudulent. An investigator can help you look for indications of a fraudulent claim. Enough of them, and he or she will recommend that surveillance be conducted on the claimant to investigate the alleged injury further.
When investigating, be sure to take an especially good look at the lawyer and doctor that the claimant uses. Sometimes, the doctor will cooperate with an attorney who will recruit from the workforce and then send that person to the doctor for treatment. The doctor will often inflate the medical bill, or submit a claim for treatment, which the claimant never received.
signs of a fraudulent claim
- has a history of claims and, or fraud
- was newly hired when they claimed the injury
- changed his/her account of the incident
- has a history of visiting unethical doctors, and lawyers
- reported the injury on Monday morning
- claimed the injury after being disciplined, laid off, or after missing out on a promotion
- refused diagnostic procedures (X-rays, MRI’s)
- is unusually familiar with the claims process
- has other documented health problems or injuries that are similar to the one claimed
- works in a busy area, but no one witnessed the injury
- was examined by more than one doctor, when one is sufficient to meet his/her needs
- has relatives that do not know about the claim
- has family members with a history of worker’s compensation fraud
- often receives treatment from a doctor who is far away from where he or she lives
- was planning a vacation directly before making the claim
- is not at home during work hours
- played sports, or participated in other high-risk hobbies before the report was made
If there are witnesses, they should be interviewed shortly after the incident - when their memory is still fresh. Wait too long, and your witnesses might forget details, or worse, the claimant might contact them and convince them to be untruthful. Having a savvy investigator, who knows how to get information from a witness, is very important. He or she will be good at gaining the trust and friendship of the person, so that they feel comfortable sharing what they know. In addition, an investigator will often be able to tell the difference between a untrustworthy and truthful one, based on how they answer questions and their body language.
This is where the investigator will endeavor to determine the physical location of the claimant, using the LKA (last known address) that they found for the claimant during the search for red flags. The investigator will employ the use of pretexts (phone calls made to the claimant or their relatives) or drive by the LKA, and try to spot the claimant’s vehicle. In addition, he or she will use this time to plan a place where they can park their vehicle and set up surveillance at the residence without being detected.
Not only will the seasoned investigator be able to follow the claimant at a distance to avoid detection, they will also act quickly to get out of bad situations and be skilled in pretexting, to get information. They will blend into the environment so that they can discreetly film the claimant. he or she knows how to capture high quality video, which is embossed with the time and date and does not have audio (audio is not legal in most states) and, after a close up view of their face to prove the person's identity, shows their full body as they go about their daily activities.
After the authorized hours of surveillance are completed, an experienced investigator should be able to provide you with a well-written report. This is probably the most important part of any worker’s compensation investigation. The report must have proper formatting and be concise, accurate, and clear.
Most cases never end up in court, but if yours does, an experienced, and ethical investigator can help you win your case by acting in a professional manner, and because of the his or her reputation as a credible witness.