The trend of insurance fraud is on the rise globally, and the financial loss is greater than many think. The Coalition Against Insurance Fraud estimates that illegal insurance claims cost about $ 80 billion each year and that 10 percent of people think insurance fraud is a victimless crime. Fraudulent claims raise the price of insurance for everyone, so it is in the best interest of the company to check whether every claim is legitimate and accurate. Car accidents, personal injuries, workplace injuries, and property damage are common insurance claims that require investigation. Read on to find out what this type of investigation entails, examples of common claims, and what are the key steps to take when conducting an insurance claims investigation.
Consumers feel the impact of this mass theft through higher premiums. Excluding health insurance, the FBI estimates that insurance fraud costs the average American family between $ 400 and $ 700 a year. Our team works to protect our clients from being victims of insurance fraud and helps combat costly impacts on our industry. With our professional insurance claims investigation service, you can easily separate truth from fiction.
What is an insurance claims investigation?
Insurance companies often conduct claims investigations to assess the legitimacy of claims. The claims investigation process itself is one in which insurance companies, insurance examiners or investigators obtain information to assess claims. The investigation process helps the claims controller make an educated decision on how to proceed with the claim. As a result, it may be necessary to review documents, locate witnesses; visit and interview people, and inspect property such as vehicles, accident sites, and physical locations, to name a few.
These investigations can lead to photography, video recording, locating witnesses, interviewing victims, observers, employers, and more. Investigators are looking for evidence that the claim is legitimate or illegitimate. Note that other services related to the requirements listed in this section may be required to obtain these answers.
Insurance claims investigations are used to combat the prevalence of false or inflated claims. An illegitimate claim is unjustified or incorrect, and by early detection, you avoid paying potentially significant costs to the fraudster. Investigation claims investigations rely on evidence, interviews, and records to determine whether a claim is legitimate or illegitimate.
There are several types of insurance investigations depending on the claim that is submitted.
Why are Claims Investigations needed?
Unfortunately, Claims Investigations are needed because, although many claims are legitimate, there are some that are not. Statistically, these illegitimate claims conservatively cost CHF$ 80 billion dollars annually across all lines of insurance. We work with Insurance Companies, Employers, and Attorneys in a defense capacity. We handle a variety of claims. Some of these are listed below:
Asbestos Claims
Bodily Injury Claims
Disability Claims Defense
FMLA (Family Medical Leave Act)
Insurance Claims
Intellectual Property Claims
Liability Claims
Medical Malpractice Claims
Mesothelioma Claims
Motor Vehicle Accident Claims
Product Liability Claims
Slip and Fall Claims
Workers ’Compensation Claims
Other Claims as Needed
Our national network of experienced field investigators and specialists is trained to verify the legitimacy of claims and to identify, diligently monitor and deter fraudulent activities in multiple insurance lines. We support the Zurich Claims Unit by providing fraud information to support timely, fair, and accurate claims decisions and refunds of payments made on the basis of false claims.
Services in support of Claims Investigations
Our team members hold designations as Certified Fraud Examiners, Certified Insurance Fraud Investigators, Fraud Claim Law Specialists, Associates in Claims, and Senior Claim Law Associates. Our investigators have deep knowledge of all common areas of fraud, including but not limited to:
Bodily injury
Heavy equipment theft
Incendiary fires
Medical provider referral schemes
Medical provider billing practices
Organized ring activity
Staged accidents
Vehicle theft
Vehicle finance fraud
We use a wide range of resources to reveal fraud and call on an extensive network of highly qualified vendors to help with:
Preliminary Record Searches
Preliminary Record Searches are defined by the investigative industry as a check of public record sources as well as investigative and proprietary databases. These searches can also be referred to in part as Background Investigations or Background Checks. Our agency Private Investigator Switzerland is that is well equipped to handle your Preliminary Record Searches.
Preliminary Record Searches can be performed independently, in conjunction with, or as a precursor to utilizing our Surveillance Services. They can also be performed as a part of Claims Investigations, Theft Investigations, Internal Investigations, Fraud Investigations, High-Risk Terminations, or other legitimate business needs. Additionally, information obtained can often uncover other potential leads. These include but are certainly not limited to witness locates and subsequent interviewing and statement taking.
What are the benefits of conducting Preliminary Record Searches?
The answer to this question will vary depending on the type of investigation or claim you are responsible for handling. For example, let’s say you have an employee who is out on a workers’ compensation claim for a back injury, or you are an insurance adjuster who has a person claiming a neck injury as a result of a low-speed impact. Preliminary Records Searches can uncover civil litigation where the subject has sued for the same type of injury or the location of a medical record which may show that the subject was seen at a hospital shortly before the date of loss. You can check out an attorney for filing bankruptcy if there is a bankruptcy-related issue. Another example could involve theft or fraud investigations. Potential information that could be gleaned includes financial problems of the subject including bankruptcies, liens, and judgments. This could be helpful in establishing a motive.
A third example could involve a high-risk termination. Knowing whether or not your employee has had any prior criminal or civil history involving violence is crucial, especially in today’s society where workplace violence is almost a daily news event.
Surveillance Services
If you are in need of Surveillance Services and you are a Workers’ Compensation Attorney, a Self-Insured Employer, a Claims Adjuster for a Third Party Administrator, an Insurance Adjuster in defense of a claim, or have any other legitimate business need, look no further. Private Investigator Switzerland is a well-respected, time-tested professional investigative agency that is well equipped to handle your surveillance needs.
Why are Surveillance Services necessary?
There are several reasons to conduct surveillance – many of which are claims related but not always. The most popular explanation is to verify the validity of the claim or concern. Listed below are some possible circumstances that may prompt you to use these services:
Alive and Well Checks
Asbestos Claims
Bodily Injury Claims
Claims Investigations Defense
Disability Claims Defense
FMLA (Family Medical Leave Act)
Fraud Investigations
Insurance Claims
Medical Malpractice Claims
Mesothelioma Claims
Motor Vehicle Accident Claims
Non-Compete Investigations
Product Liability Claims Defense
Slip and Fall Claims
Theft Investigations
Workers’ Compensation Claims
Other Legitimate Business Needs
Can Surveillance Services make a difference?
The answer is…YES! Surveillance Services can make a difference in any number of situations. Are you hearing any rumors? Maybe you shouldn’t ignore them. What if they are true? Think of these services as your eyes to reveal what is truly taking place. Ever heard of the saying “Out of sight, Out of mind” it’s true. “If you don’t look, you won’t know”.
Witness Locates
Witness locates are becoming more commonly requested especially if there has been an accident, incident, or event. You have to ask yourself, did somebody see something? The more complete questions are:
Who are the witnesses?
Where do they live?
How do I contact them?
What did they see?
We live in a transient society. It is no longer the norm to live in the same house for a lifetime as it may have been in days gone by. We are frequently called upon to help our clients in instances where the individual's domicile can’t be easily verified. People move for many reasons and staying in touch with a witness, an insured, a subject, a defendant or a client can be quite difficult. The necessity to make contact is great. The final outcome of a trial may be hinging on the testimony of a witness and you have no idea how to reach them.
Our years of experience, proprietary databases, and contacts, along with old fashion street work, have helped make us very successful in assisting our clients. Our success stories include finding individuals who have relocated out of the country, and yes, we have determined the whereabouts of individuals living in boxes and under bridges. Let us use our tools, expertise, and our knowledge to help you. If we are not your “go-to” company for witness locates, maybe we should be!
Fraud Investigations
Fraud is a general term used to describe an act of deceit by an individual or group. This act of deceit can come in many different forms. For example, insurance fraud investigators try to expose those who make false claims in order to get insurance money. Intellectual property fraud occurs when fake products are passed off or sold as originals. Mortgage fraud occurs when somebody has falsified the paperwork to ensure the loan goes through. Since each of the above are examples of fraud, then investigating them would fall under the classification of Fraud Investigations.
In the course of doing your job do you ever get a sense that things are a bit wrong? Sure you do. Listed below are possible areas where fraudulent activities occur and how Fraud Investigations begin:
Bodily Injury Claims
Disability Claims
FMLA(Family Medical Leave Act) Abuses
Insurance Claims
Intellectual Property Claims
Liability Claims
Medical Malpractice Claims
Mortgage Fraud Claims
Motor Vehicle Accident Claims
Product Liability Claims
Workers Compensation Claims
Other Legitimate Business Needs
Investigating the fraud or potential fraud…
Fraud is a huge problem that costs people and companies billions of dollars every year. It can take on many forms. Investigating the fraud or potential fraud may require extensive database searches, reviewing public records, retrieving documents, locating witnesses, interviewing and statement taking, and surveillance as well as the use of other investigative tools.
Provide us with as much information as you have…
Fraud Investigations, like all others, can be initiated by a face-to-face meeting, e-mail, using our encrypted online case opening, or by simply calling our offices. Details as to the type of fraud suspected, as well as any evidence that may exist, should be provided to us as your private investigators. “Nothing means nothing until it means something”. What does that mean? It means your job is to provide us with as much information as you have whether you think is important or not. You ask why? The answer is that the smallest detail could be used later to solve the case.
What is our mission?
Our mission is to provide you with accurate reliable information so that you have the evidence and facts needed to verify or refute the suspected fraud. Use our years of experience and expertise to look into these matters for you.
In addition to the above, we also use:
Mobile device and vehicle “infotainment” forensics
Accident reconstruction and injury analysis
Medical, pharmaceutical, and other canvasses
Innovative new tools to aid in decision-making
What types of claims are there?
Worker compensation claims
Fraudulent claims for workers' compensation can be dangerous to your company's financial well-being. In order to determine the legitimacy of the claim, the examiner will conduct an investigation into the claim for workers' compensation.
The investigation seeks to establish two things:
Is the employee as injured as they claim he is?
Did the injury occur while the person was working?
For example, an employee who was injured outside of work on Tuesday night, but came the next day and filed a lawsuit alleging that the injury occurred at work, would file a false report of the worker. Ideally, an investigation would uncover that lie.
Claims for personal injury
Fraudulent claims for personal injury can be just as dangerous as false claims for workers' compensation. Personal injury lawsuits can be filed either against the company or against another person. The claim becomes false when the victim fell on her own icy steps, but she staged the incident so that it looks as if it happened in front of the company's shop window.
Claims for property damage and theft
Insurance companies will also investigate material damage (e.g., fire damage, water damage, or traffic accident) and theft claims (e.g., theft, burglary, kidnapping, or robbery). Depending on the assets and requirements, the investigator may call an expert. For example, they could ask someone to come in and assess the patterns of burns to find out the origin and cause of the fire. The information obtained through this process will help the examiner to confirm or deny that the claim is legitimate.
Lawsuits for health care / medical fraud
These claims are being investigated by private and public insurers, such as Medicare and Medicaid. Both the practitioner and the patient may engage in false or inflated health claims, sometimes together, to fill their pockets. According to the Institute of Legal Information, statistics now show that 10 cents of every dollar spent on health care goes to pay for false health care claims.
The claims investigator’s job is to investigate the claim and present the findings so the customer can make a reasonable decision based on facts, call us today!
Private Investigator Switzerland
Schaffhauserstrasse 550.
CH-8050 Zürich
Switzerland
T. +41 44 586 60 33
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