Insurance investigator

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An insurance investigator examines insurance claims that are suspicious or otherwise in doubt. Investigators in this field have differing specialties and backgrounds. Some insurance companies have their own in-house investigation teams while other companies sub-contract the work to private investigators or private investigation firms. [1] Although such investigations are usually conducted to combat fraud, very often investigators will be working simply to establish the circumstances of a particular claim (for example, in a multi-vehicular road accident involving various parties, claims and insurance companies).

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Insurance fraud

Methods of defrauding insurance companies are manifold, as are the means of investigating them. As a crime, however, evidence shows that insurance fraud in wealthy nations is increasing, with many governments running public awareness campaigns to deter potential fraudsters and appeal to the public to report any suspicious claims. [2]

One of the most common forms of insurance fraud is the exaggeration of injuries. Because many injuries can be exceptionally difficult to quantify (for example, psychological injuries or physical injuries such as whiplash), investigators will often seek to establish that what the claimant claims is true (for example, if a claimant states he or she cannot work) and that there are no obvious discrepancies in the symptoms claimed (very often examined in conjunction with medical staff). Surveillance is often employed in such circumstances to verify the claim.

Another form of lesser known fraud is that of claiming on an insurance policy for injuries sustained before the policy came into effect. For example, in a road accident, a person may claim to have sustained a debilitating back injury. On investigation, however, it transpires that the injury had been sustained in an incident some months or even years before. Very often insurance companies and investigators will study medical reports and history to eliminate this possibility, as well as searching for evidence of previous claims or accidents.

There are also many forms of fraud involving property, for example when a person with valuable assets (property, for example) deliberately destroys them, often through arson, with the intention of then claiming the value back through insurance. Another form would be an art collector insuring a high value piece and then having it 'stolen' - claiming the money for himself and keeping the art piece in the process. [3]

In fiction

Between 1927 and 1937 the insurance investigator Miles Bredon appeared on a series of novels by the British author Ronald Knox. Employed by the large London-based Indescribable Insurance Company, Bredon is frequently called in to fix puzzling cases as one of the Golden Age Detectives. [4] Yours Truly, Johnny Dollar , which aired on the CBS Radio Network from 1949 to 1962, featured "the transcribed adventures of the man with the action-packed expense account – America's fabulous freelance insurance investigator."

Related Research Articles

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<span class="mw-page-title-main">Insurance</span> Equitable transfer of the risk of a loss, from one entity to another in exchange for payment

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<span class="mw-page-title-main">Fraud</span> Intentional deception made for personal gain or to damage another individual

In law, fraud is intentional deception to secure unfair or unlawful gain, or to deprive a victim of a legal right. Fraud can violate civil law or criminal law, or it may cause no loss of money, property, or legal right but still be an element of another civil or criminal wrong. The purpose of fraud may be monetary gain or other benefits, for example by obtaining a passport, travel document, or driver's license, or mortgage fraud, where the perpetrator may attempt to qualify for a mortgage by way of false statements.

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Forensic accounting, forensic accountancy or financial forensics is the specialty practice area of accounting that investigates whether firms engage in financial reporting misconduct, or financial misconduct within the workplace by employees, officers or directors of the organization. Forensic accountants apply a range of skills and methods to determine whether there has been financial misconduct by the firm or its employees.

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Personal injury is a legal term for an injury to the body, mind, or emotions, as opposed to an injury to property. In common law jurisdictions the term is most commonly used to refer to a type of tort lawsuit in which the person bringing the suit has suffered harm to their body or mind. Personal injury lawsuits are filed against the person or entity that caused the harm through negligence, gross negligence, reckless conduct, or intentional misconduct, and in some cases on the basis of strict liability. Different jurisdictions describe the damages in different ways, but damages typically include the injured person's medical bills, pain and suffering, and diminished quality of life.

Total Permanent Disability(TPD) is a phrase used in the insurance industry and in law. Generally speaking, it means that because of a sickness or injury, a person is unable to work in their own or any occupation for which they are suited by training, education, or experience. An individual or group of individuals can insure themselves against it through a disability insurance policy, as part of a life insurance package or through worker's compensation insurance.

<span class="mw-page-title-main">Accident Compensation Corporation</span>

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A demand letter, letter of demand,, or letter before claim, is a letter stating a legal claim which makes a demand for restitution or performance of some obligation, owing to the recipients' alleged breach of contract, or for a legal wrong. Although demand letters are not legally required they are frequently used, especially in contract law, tort law, and commercial law cases. In some cases, evidence of attempts to settle are required before a court case will be accepted by the court, and demand letters are commonly used to fulfill this requirement. For example, if one anticipates a breach, it is advantageous to send a demand letter asserting that the other side appears to be in breach and requesting assurances of performances. Demand letters that are not responded to may constitute admissions by silence. Also, a demand letter will often generate a denial letter stating the basis for rejecting claim, and is sometimes a good indication of what defenses will be raised if a suit is brought later.

In the English law of negligence, the acts of the claimant may give the defendant a defence to liability, whether in whole or part, if those acts unreasonably add to the loss.

Richardson v. Perales, 402 U.S. 389 (1971), was a case heard by the United States Supreme Court to determine and delineate several questions concerning administrative procedure in Social Security disability cases. Among the questions considered was the propriety of using physicians' written reports generated from medical examinations of a disability claimant, and whether these could constitute "substantial evidence" supportive of finding nondisability under the Social Security Act.

In many legal jurisdictions, the manner of death is a determination, typically made by the coroner, medical examiner, police, or similar officials, and recorded as a vital statistic. Within the United States and the United Kingdom, a distinction is made between the cause of death, which is a specific disease or injury, versus manner of death, which is primarily a legal determination, versus the mechanism of death, which does not explain why the person died or the underlying cause of death and can include cardiac arrest or exsanguination.

<span class="mw-page-title-main">Forensic epidemiology</span>

The discipline of forensic epidemiology (FE) is a hybrid of principles and practices common to both forensic medicine and epidemiology. FE is directed at filling the gap between clinical judgment and epidemiologic data for determinations of causality in civil lawsuits and criminal prosecution and defense.

Asbestos bankruptcy trusts are trusts established by firms that have filed for reorganization under Chapter 11 of the United States Bankruptcy Code to pay personal injury claims caused by exposure to asbestos. At least 56 such trusts were established from the mid-1970s to 2011.

Workers' compensation in the United States is a primarily state-based system of workers' compensation.

References

  1. ↑ "10.23.2 Contractor Investigations". 9 November 2022.
  2. ↑ Pennsylvania Office of Attorney General Strawberry (9 November 2022). "Types of Insurance Fraud".
  3. ↑ Detektei Fahtz (9 November 2022). "Detektei" (in German).
  4. ↑ Reilly, John M. Twentieth Century Crime & Mystery Writers. Springer, 2015.p. 912
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