Fraud Control within the Insurance Industry

Identifying a crime to prepare your defense

 Workers Compensation Fraud

It has been estimated that insurance fraud takes approximately $100 billion dollars per year from the Insurance Industry. The state of California’s Legislature has made the fight against insurance fraud, the public policy of the state. It has stated that prevention of health, workers’s compensation, property and casualty insurance fraud will save the public billions of dollars in unnecessary increased health care and workers compensation costs.

Our Investigators will act aggressively to defend both Insurance Companies and Self Insured entities, in an effort to minimize those losses due to a fraudulent claim, by employing both Surveillance Private Investigators and Private Investigators skilled in claim based interviews, where fraud is suspected.

The Staged Accident

An insured person, in collusion with others, drives his vehicle into the rear of a car occupied by four co-conspirators. He reports the “accident” to his insurer as an accident that was his fault. The occupants of the other car all claim to suffer soft tissue injuries and make a claim against the insured.  Soft tissue injuries are strains and sprains which have no objective symptoms and are, therefore rather easy to fake. No one can read the claimants mind and disprove his subjective complaints of pain. There are no effective tests available to a physician to accurately determine whether a person is being honest when he or she complains of pain. Quick settlement is reached with the “victims” of the “accident” who share the proceeds received from the fraudulent claim.

The Non-existent Trip-and-fall

An uninjured person reports slipping and falling on debris in a business establishment. The Claimant presents medical reports from a physician or chiropractor to establish the extent of his injury. The Claimant is always willing to settle the injury for a reasonable sum rather than involve an Attorney.

The Short-Stop

Sometimes called the “swoop and squat”. The Claimant, is driving an old and dented automobile, stops suddenly in front of an expensive automobile, which has no choice but to rearend the old vehicle. A Claim is presented for extensive physical injuries.

The Inflated Claim

Although the claimant actually suffered a loss, he seeks to profit from it by reporting items of damage or injury that are in excess of their true value. The Claimant may exaggerate the value of his property, thru fictitious receipts or photos related to the property “upgrades”.  The Claimant sources a chiropractor or physician who is willing to submit billings for services never performed in exchange for a split of the recovery. The claimant knows the symptoms of a soft tissue injury sufficiently so that he can convince a legitimate doctor that he was injured.

John Nobriga is the owner of JMN Investigations & Protective Services. Specializing in Insurance defense investigations for: Insurance companies, Self-insured entities and Third party administrators.

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