June 15, 2015

 The facts of the loss are not the only things that can indicate fraud. The behavior of the claimant can also indicate that the claim or parts of it could be falsified, exaggerated, or otherwise fraudulent. At times claimants and insureds may work together to perpetrate a fraud. The following checklist can help identify when actions of the claimant indicate that further investigation should be conducted. Three or more of these factors indicate that the claim should be referred to investigators for further research.

 

____Retains or is represented by counsel on the day of the loss/immediately after claim is reported

 

____Represented by a public adjuster on the day of the loss

 

____Wants a settlement approved quickly

 

____Does not want the claim to go to a supervisor, regional office, or claims committee for authority

 

____Is exceedingly cooperative and undemanding

 

____Is exceedingly demanding and threatens a bad faith suit from the date of first contact

 

____Demands a proof of loss form at the initial meeting

 

____Is familiar with insurance claims terminology

 

____Asks for the claims manager by name

 

____Is familiar with the adjuster's authority limits and wants to settle for a sum within those limits

 

____Handles all business in person (thus avoiding mail and potential prosecution for violation of federal mail fraud statutes)

 

____Provides an address that is a post office box, mail drop, or hotel

 

____Reduces the demand for settlement when it is suggested by the adjuster that he file suit

 

____Has a history of multiple, similar claims

 

____Has a history of more than two lawsuits

 

____Is recently separated or divorced (indicating a possible financial strain)

 

____Was recently laid off a job, has a spotty work history, or extended period of unemployment

 

____Has a history of gambling, alcohol, or drug abuse

 

____Insured is eager to accept blame for an accident.

 

____Claimant and insured know each other.

 

____Claimant and insured are from the same family.

 

____Claimant and insured have the same address.

 

____One or more parties present damages that are inconsistent with the facts of the loss.

 

____Claimant's lost earnings statement is handwritten or typed on blank paper rather than business letterhead.

 

____Claimant has multiple insurance claims.

 

____Several or all claimants treated at same clinic on same day.

 

____Vehicle was purchased for cash.

 

____Claimant has no proof of ownership of vehicle.

 

____Vehicle recovered was surgically stripped.

 

This premium content is locked for FC&S Coverage Interpretation Subscribers

Enjoy unlimited access to the trusted solution for successful interpretation and analyses of complex insurance policies.

  • Quality content from industry experts with over 60 years insurance experience, combined
  • Customizable alerts of changes in relevant policies and trends
  • Search and navigate Q&As to find answers to your specific questions
  • Filter by article, discussion, analysis and more to find the exact information you’re looking for
  • Continually updated to bring you the latest reports, trending topics, and coverage analysis