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.