LOS S
C O N T ROL
A L E R T
Reporting Suspected Fraud Can Benefit Employers
Insurance fraud costs policyholders billions of dollars each year in the form of increased premiums. Reporting suspected claim fraud is
a policyholder’s responsibility and may help reduce the impact that fraud has on insurance costs. Often, a policyholder may be reluctant to report suspected claim fraud. Reasons for this reluctance may include:
•
•
•
The time and effort to report their suspicions produces little results
Uncertainty regarding how to report their suspicions
A perception that their information may not be sufficient to initiate an investigation
As a member of the National Insurance Crime Bureau, Everest’s Special Investigation Unit (SIU) is serious about fraud prevention and
detection. Investigating all suspected fraud and submitting those cases for prosecution when sufficient evidence exists, Everest boasts
a zero tolerance fraud policy. Examples of recent successes by Everest’s Special Investigation Unit include:
1.
A claimant reported work-related physical injuries and psychological distress resulting from a rear-end traffic accident. Surveillance
discovered the claimant driving and performing other activities that were contrary to the reported injuries. The claimant quickly
recanted the claim and admitted that she actually felt BETTER after the accident! Everest SIU referred this case for criminal prosecution.
2.
A claimant reported a work related left wrist injury. An Everest SIU investigation discovered that the claimant had a long history of
injuries to this left wrist; provided a false medical history; and denied prior wrist injuries. Everest SIU referred this case for criminal
prosecution and the claimant was charged for insurance fraud.
3.
A claimant reported work-related leg injuries resulting in temporary total disability. Surveillance found the claimant performing
tasks contrary to the reported injuries. It was further discovered that the claimant had concurrent employment at a “Temp Agency”
and was also collecting state disability benefits. The claimant was successfully prosecuted for felony insurance fraud.
4.
A claimant reported work-related injuries resulting from a tripping accident. The claim ended with a substantially reduced settlement and referral for criminal prosecution. Acting on information reported by the claimant’s employer, subsequent surveillance
found the claimant performing physical activities in direct conflict with her alleged restrictive abilities. Faced with the evidence,
claimant counsel quickly capitulated to a much lower settlement.
5.
A claimant was charged with felony insurance fraud because of an Everest SIU investigation. Following tips from the employer, the
investigation discovered that the claimant submitted several falsified documents in an effort to receive additional workers’ compensation benefits. Claimant surveillance also found the claimant performing tasks contrary to the claimed injuries.
These are but a few examples of the impact of Everest’s Special Investigation Unit and our commitment to prevent insurance fraud. To
report suspected fraud, please contact Everest SIU directly at 908-604-7255 or by an email to [email protected]. All reports are held
in confidence.
Remember, Everest Loss Control offers services to help you in your loss prevention efforts. If you would like more information about
these services, visit our web site at www.everestnational.com.
Loss Control is a daily responsibility of your individual management. This publication is not a substitute for your own loss control program. The information
that is provided in this Alert should not be considered as all encompassing, or suitable for all situations, conditions, or environments. Each organization is
responsible for implementing their safety/injury/illness prevention program and should consult with legal, medical, technical, or other advisors as to the
suitability of using the information contained in this Alert. The information contained in this publication is intended for general informational purposes
only and is not intended to constitute legal advice or opinions. You should contact an attorney if you need legal advice and/or you have any questions
concerning your obligations under any law, statute and/or code identified in this publication.
CONTACT US
Westgate Corporate Center
477 Martinsville Road
P.O. Box 830
Liberty Corner, NJ 07938-0830
Everest focuses on specialty property and casualty insurance business and is
licensed to conduct business in all 50 states, including the District of Columbia.
Everest is rated A+ XV (Superior) by A.M. Best. To learn more about Everest,
visit our website at : www.everestnational.com
Reporting Suspected Fraud Can Benefit Employers
Loss Control Department
Phone: 908-604-3000
Fax: 908-604-3526
E-mail: [email protected]
November 2010