Insurance fraud is a huge problem and insurance companies have gotten a reputation for being hard to work with on insurance claims. They see a lot of fraud and the red flags that pop up are taken very seriously.
is called in by insurance companies when they see red flags. We don’t make decisions on cases. Our job is to find facts. Sometimes the facts just keep compounding.
In one workers compensation fraud investigation, we were asked to surveil a claimant to determine if the patient was really disabled. Workers comp fraud is everywhere and the premiums are very expensive, in part because of the amount of fraud.
Workers compensation investigation can include documenting the claimant’s activity as well as their contact with medical providers. In this case, one blossomed into another investigation.
Cathy* had taken a tumble at work and allegedly injured her back. She was seeing a chiropractor for the injury. Every week she had an appointment at the clinic and was wearing a back brace. After six weeks, she had informed the insurance company that the chiropractor extended the treatment plan and she could expect at least another six weeks of treatments. That’s when the insurance company began the investigation.
Using surveillance equipment we were able to document her activities including raking leaves and getting up on ladders to clean out gutters. We also documented the installation of about 30 bags of mulch throughout the gardens at her home.
When the insurance company approached her with the evidence, she was very sincere in her statements that she thought she was doing okay, but the chiropractor insisted she continue treatment for another six weeks.
The workers compensation fraud investigation was extended to include other patients of this particular medical practitioner. The same scenario played out with all but one of the other patients. Each was documented participating in activities that seemed outside the scoop of what they should be capable of doing, if they were, indeed, disabled. And each thought they were well enough to return to work without restriction but the health care provider advised them all to continue treatment.
Insurance fraud investigators shifted their investigation to the practice itself. After electronic surveillance identified several parties who visited the clinic and then, within a couple of weeks, were being seen as patients, the possibility of an organized fraud was raised.
Eventually there was enough evidence for the chiropractor to be arrested and charged with fraud. He went to trial and Cathy went back to work.
Workers comp fraud, disability insurance fraud and fraud in slip and fall accidents is a challenge for insurance companies. But as we were able to show in this case, it might not be the patient who is committing the fraud. You have to have the facts. That’s where comes in. We get the facts.
-Brenda McGinley, CEO, All in Investigations, All in Investigations
*Name changed
