Nov 132023

Insurance fraud is one of the biggest problems facing the insurance industry today. It is estimated that between 10% and 33% of all insurance claims contain some element or degree of fraud. Each year, fraud costs the insurance industry $96 billion. And in just the Property and Casualty industry alone, insurance fraud costs are more than $23 billion.

But some are doing something about it. ( sponsored by independent investigators David Morse & Associates, gives information and resources on how to fight insurance fraud. The site also features stories of successful investigations that resulted in the bust of a fraud perpetrator. And when a fraud perpetrator is busted, that helps everyone, because it helps to bring insurance premiums down.

Dance with Me to the Hospital Darling
By Jim Smith, Deputy Director, DMA Investigations

“Through years of investigations, I have often found it to be true that a fraudulent claim is a solution to a problem, and if you find out what the problem is that the person is having, you have the solution to your fraudulent claim.

“Something didn’t seem right. A nurse had claimed a significant knee injury. She returned to work, then had to take off again, then back to work, then off again.

“Your trusty investigator was called in to do some surveillance and try to find out what this woman was doing while off work on a Workers Comp claim, with her significant knee injury.

“We observed and filmed her doing a wide range of normal activities, such as shopping, driving, and taking her kids to school.

“The fact that the subject showed no signs of bodily distress – the knee was not wrapped, no cane or crutches, plus the fact that she was conducting normal activities with no apparent difficulties – was the red flag that justified more surveillance.

“Shortly thereafter we filmed the subject being transported by ambulance to the hospital Emergency Room, screaming and hollering and making a fuss. In the ER, she claimed she had slipped in the shower, and demanded a specific heavy pain medication, which she was given.

“Within a week, we got film of the subject out bowling with hubby and friends for two hours, again with no apparent difficulties. Hmm.

“Within seven days of bowling, Mrs. Free and Easy turned into Mrs. Drama Queen again, with another ambulance transport to the hospital, once again screaming and hollering. Once again in the ER she said she injured herself, again by herself with no witnesses, and once again demanded her specific heavy pain medication. Doctors noticed that the type of medication demanded seemed inconsistent with the degree and type of injury.

“More surveillance was indicated. A week after the high drama ride to the ER, we got an anonymous tip that the subject had a wedding anniversary coming up, and had a big shindig scheduled at a rented hall. We suspected she might have been bragging about her time off on the company dime, and that angered one of her friends enough to tip us off. Anyway, our intrepid investigator managed to get an invitation to the party!

“So we attended the party, and surprise, surprise. We found, and filmed, our subject dancing the night away for two hours. No screaming, no hollering, no ambulances. Party Queen instead of Drama Queen.

“Shortly thereafter, the subject was interviewed by her employer, and confronted with the film we had taken, and the fact that she appeared completely normal with no knee difficulties (while out on a Workers Comp claim), other than during her hysterical trips to the hospital. Someone who is so injured they can’t work, is not usually found bowling and dancing for hours at a time.

“She finally confessed to the fact that she was addicted to painkillers. She had a prescription for these, but when the prescription would run out she would fake another injury or relapse, along with a highly dramatic trip to the ER, so she could get another fix.

“So the problem (addiction to painkillers) caused her to fake a claim. Our film of inconsistent behavior broke the case and elicited the confession. We heard she was in rehab shortly thereafter.”

Another victory for truth, justice, and lower insurance premiums.

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