Insurance fraud is a crime, defined as "when someone knowingly and with intent to defraud, presents or causes to be presented, any written statement that is materially false and misleading to obtain some benefit or advantage, or to cause some benefit that is due to be denied."
In simpler terms, insurance fraud means that someone submits an insurance claim that is not an accurate reflection of what happened, usually to receive money. In the Workers Compensation arena, this often means the person claims some degree of disability, saying they are injured and cannot work, when in fact they can work. In other words, in fraudulent cases, the person says they're injured but they really aren't, or are not injured as badly as they claim.
When a case is suspicious, containing "red flag" indicators of possible fraud, an investigator is often brought in to find out the true facts of the case. David Morse & Associates (http://www.davidmorse.com) investigates suspicious cases, conducts surveillance, and if an insurance claim is found to be fraudulent, turns the information over to the insurance company.
This is a case from the David Morse & Associates Investigations archives, Part 7 of the Fraud Chronicles, involving a case where the person claiming to be disabled was found to be doing strenuous work on her vehicle.
The Perils of Car Maintenance
By Jim Smith
Deputy Director, DM&A Investigations
"Normally car maintenance is an activity that is good for morale and poses no threat to the individual providing care for his or her equipment. But a person claiming disability and attempting to collect Workers Comp benefits ought to know better than to clean a car, increase tire pressure, open and close garages and perform similar tasks. The potential of a large 'gift' from Workers' Compensation would theoretically incline the truly devious person to require such tasks to be performed by a spouse, a 'significant other' or a hired hand.
"Our female subject claimed left arm, left leg and back injuries and was collecting benefits. She was reportedly using a cane. The assignment was for two days of surveillance.
"The subject's residence was one of ten units, not visible from the street. But as luck would have it, the garage was right on the street and it turned out that our subject felt strongly in matters of vehicle maintenance. We were able to obtain video footage of her checking air in all four tires, using a pump to add air to all four tires, and then washing the car. Or to be more accurate - the mini van. The stretching and contortions necessary to clean the roof of a mini van when you are five foot one inch tall require more than an absence of disability - true dexterity and great balance are a vital necessity. Needless to say, all this involved a lot of bending, crouching, twisting, stretching, use of the left arm in lifting, etc. No sign of hesitation or pain. Not a cane in sight.
"Next we were instructed to get film of the subject's arrival at the Workers Compensation Appeals Board, her departure from home prior, and her arrival at home afterward. She left home without a cane, walking with no sign of pain. She arrived at the hearing and only then did the cane come out of the trunk of the car. In all the time we had observed her, this had been the first appearance of the cane. Her gait for the first time developed a slight hesitation.
"But all that was short-lived. By the time she was home she was apparently feeling fine, the cane went back into the trunk and she walked into her residence with ease.
"Our subject was playing hardball and took this case to trial before the Workers Comp Appeal Board. But when her attorney viewed the film the matter settled for a fraction of the demand, saving tens of thousands of dollars."
Another victory for truth, justice, and lower insurance premiums.
About the Author:
Shawn Kyles is an expert in foundation repair & house bolting, and a partner at Julian Construction (http://www.julianconstruction.com) in Los Angeles. He has inspected over 15,000 structures, working with engineering firms & local departments of building & safety. Julian Construction owns its own company and is a “no middlemen” model--no salesmen or subcontractors--you get the principals of the company & its workers under your home. The company’s blog is http://julianconstruction.typepad.com/
David Morse & Associates Fraud Chronicles 7: Perils of Car Maintenance
