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]

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

Insurance is a means of protection from financial loss in which, in exchange for a fee, a party agrees to compensate another party in the event of a certain loss, damage, or injury. It is a form of risk management, primarily used to protect against the risk of a contingent or uncertain loss.

<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.

<span class="mw-page-title-main">Forensic engineering</span> Investigation of failures associated with legal intervention

Forensic engineering has been defined as "the investigation of failures—ranging from serviceability to catastrophic—which may lead to legal activity, including both civil and criminal". The forensic engineering field is very broad in terms of the many disciplines that it covers, investigations that use forensic engineering are case of environmental damages to structures, system failures of machines, explosions, electrical, fire point of origin, vehicle failures and many more.

<span class="mw-page-title-main">Life insurance</span> Type of contract

Life insurance is a contract between an insurance policy holder and an insurer or assurer, where the insurer promises to pay a designated beneficiary a sum of money upon the death of an insured person. Depending on the contract, other events such as terminal illness or critical illness can also trigger payment. The policyholder typically pays a premium, either regularly or as one lump sum. The benefits may include other expenses, such as funeral expenses.

<span class="mw-page-title-main">Forensic accounting</span> Branch of accounting which investigates financial misconduct and fraud

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.

Insurance fraud is any act committed to defraud an insurance process. It occurs when a claimant attempts to obtain some benefit or advantage they are not entitled to, or when an insurer knowingly denies some benefit that is due. According to the United States Federal Bureau of Investigation, the most common schemes include premium diversion, fee churning, asset diversion, and workers compensation fraud. Perpetrators in the schemes can be insurance company employees or claimants. False insurance claims are insurance claims filed with the fraudulent intention towards an insurance provider.

<span class="mw-page-title-main">English tort law</span> Branch of English law concerning civil wrongs

English tort law concerns the compensation for harm to people's rights to health and safety, a clean environment, property, their economic interests, or their reputations. A "tort" is a wrong in civil law, rather than criminal law, that usually requires a payment of money to make up for damage that is caused. Alongside contracts and unjust enrichment, tort law is usually seen as forming one of the three main pillars of the law of obligations.

Benefit fraud is a form of welfare fraud as found within the system of government benefits paid to individuals by the welfare state in the United Kingdom.

<span class="mw-page-title-main">Personal injury</span> Legal term for an injury to a person

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>

The Accident Compensation Corporation (ACC) is the New Zealand Crown entity responsible for administering the country's no-fault accidental injury compensation scheme, commonly referred to as the ACC scheme. The scheme provides financial compensation and support to citizens, residents, and temporary visitors who have suffered personal injuries.

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.

Uninsured employer in the United States is a term to identify an employer of workers under circumstances where there is no form of insurance in place to provide certain benefits to those workers. More specifically, it is a term used in workers’ compensation law to identify an employer who does not have some form of worker's compensation insurance or self-insurance coverage in effect at the time of, or during the time of, a claimed injury.

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. Different categories are used in different jurisdictions, but manner of death determinations include everything from very broad categories like "natural" and "homicide" to specific manners like "traffic accident" or "gunshot wound". In some cases an autopsy is performed, either due to general legal requirements, because the medical cause of death is uncertain, upon the request of family members or guardians, or because the circumstances of death were suspicious.

<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