Insurance fraud


Insurance fraud

Insurance fraud is any act committed with the intent to fraudulently obtain payment from an insurer.

Insurance fraud has existed ever since the beginning of insurance as a commercial enterprise.[1] Fraudulent claims account for a significant portion of all claims received by insurers, and cost billions of dollars annually. Types of insurance fraud are very diverse, and occur in all areas of insurance. Insurance crimes also range in severity, from slightly exaggerating claims to deliberately causing accidents or damage. Fraudulent activities also affect the lives of innocent people, both directly through accidental or purposeful injury or damage, and indirectly as these crimes cause insurance premiums to be higher. Insurance fraud poses a very significant problem, and governments and other organizations are making efforts to deter such activities.

Contents

Causes

The “chief motive in all insurance crimes is financial profit.”[1] Insurance contracts provide both the insured and the insurer with opportunities for exploitation. One reason that this opportunity arises is in the case of over-insurance, when the amount insured is greater than the actual value of the property insured.[1] This condition can be very difficult to avoid, especially since an insurance provider might sometimes encourage it in order to obtain greater profits.[1] This allows fraudsters to make profits by destroying their property because the payment they receive from their insurers is of greater value than the property they destroy.

Insurance companies are also susceptible to fraud because false insurance claims can be made to appear like ordinary claims. This allows fraudsters to file claims for damages that never occurred, and so obtain payment with little or no initial cost.

The most common form of insurance fraud is inflating of loss.

Losses due to insurance fraud

It is virtually impossible to determine an exact value for the amount of money stolen through insurance fraud. Insurance fraud is designed to be undetectable, unlike visible crimes such as robbery or murder. As such, the number of cases of insurance fraud that are detected is much lower than the number of acts that are actually committed.[1] The best that can be done is to provide an estimate for the losses that insurers suffer due to insurance fraud. The Coalition Against Insurance Fraud estimates that in 2006 a total of about $80 billion was lost in the United States due to insurance fraud.[2] According to estimates by the Insurance Information Institute, insurance fraud accounts for about 10 percent of the property/casualty insurance industry’s incurred losses and loss adjustment expenses.[3] The National Health Care Anti-Fraud Association estimates that 3% of the health care industry’s expenditures in the United States are due to fraudulent activities, amounting to a cost of about $51 billion.[4] Other estimates attribute as much as 10% of the total healthcare spending in the United States to fraud—about $115 billion annually.[5] In the United Kingdom, the Insurance Fraud Bureau estimates that the loss due to insurance fraud in the United Kingdom is about £1.5 billion ($3.08 billion), causing a 5% increase in insurance premiums.[6] The Insurance Bureau of Canada estimates that personal injury fraud in Canada costs about C$500 million annually.[7]

Hard vs. soft fraud

Insurance fraud can be classified as either hard fraud or soft fraud.[8]

Hard fraud occurs when someone deliberately plans or invents a loss, such as a collision, auto theft, or fire that is covered by their insurance policy in order to receive payment for damages. Criminal rings are sometimes involved in hard fraud schemes that can steal millions of dollars.[9]

Soft fraud, which is far more common than hard fraud, is sometimes also referred to as opportunistic fraud.[8] This type of fraud consists of policyholders exaggerating otherwise legitimate claims. For example, when involved in a collision an insured person might claim more damage than was really done to his or her car. Soft fraud can also occur when, while obtaining a new insurance policy, an individual misreports previous or existing conditions in order to obtain a lower premium on their insurance policy.[8]

Types of insurance fraud

Life insurance

An example of life insurance fraud is the John Darwin disappearance case, an ongoing investigation into the faked death of British former teacher and prison officer John Darwin, who turned up alive in December 2007, five years after he was thought to have died in a canoeing accident. Darwin was reported as "missing" after failing to report to work following a canoeing trip on March 21, 2002. He reappeared on December 1, 2007, claiming to have no memory of the past five years.

Health care insurance

According to The Coalition Against Insurance Fraud, health fraud depletes taxpayer-funded programs like Medicare, and may victimize patients in the hands of certain doctors.[10] Some scams involve double-billing by doctors who charge insurers for treatments that never occurred, and surgeons who perform unnecessary surgery. [11]

According to Roger Feldman, Blue Cross Professor of Health Insurance at the University of Minnesota, one of the main reasons that medical fraud is such a prevalent practice is that nearly all of the parties involved find it favorable in some way. Many physicians see it as necessary to provide quality care for their patients. Many patients, although disapproving of the idea of fraud, are sometimes more willing to accept it when it affects their own medical care. Program administrators are often lenient on the issue of insurance fraud, as they want to maximize the services of their providers.[12]

The most common perpetrators of healthcare insurance fraud are health care providers. One reason for this, according to David Hyman, a Professor at the University of Maryland School of Law, is that the historically prevailing attitude in the medical profession is one of “fidelity to patients”.[13] This incentive can lead to fraudulent practices such as billing insurers for treatments that are not covered by the patient’s insurance policy. To do this, physicians often bill for a different service, which is covered by the policy, than that which was rendered.[14]

Another motivation for insurance fraud in the healthcare industry, just as in all other types of insurance fraud, is a desire for financial gain. Public healthcare programs such as Medicare and Medicaid are especially conducive to fraudulent activities, as they are often run on a fee-for-service structure.[15] Physicians use several fraudulent techniques to achieve this end. These can include “up-coding” or “upgrading,” which involve billing for more expensive treatments than those actually provided; providing and subsequently billing for treatments that are not medically necessary; scheduling extra visits for patients; referring patients to another physician when no further treatment is actually necessary; "phantom billing," or billing for services not rendered; and “ganging,” or billing for services to family members or other individuals who are accompanying the patient but who did not personally receive any services.[15]

Perhaps the greatest total dollar amount of fraud is committed by the health insurance companies themselves. There are numerous studies and articles detailing examples of insurance companies intentionally not paying claims and deleting them from their systems[16], denying and cancelling coverage, and the blatant underpayment to hospitals and physicians beneath what are normal fees for care they provide.[17] Although difficult to obtain the information, this fraud by insurance companies can be estimated by comparing revenues from premium payments and expenditures on health claims.

Automobile insurance

The Insurance Research Council estimated that in 1996, 21 to 36 percent of auto-insurance claims contained elements of suspected fraud.[18] There is a wide variety of schemes used to defraud automobile insurance providers. These ploys can differ greatly in complexity and severity. Richard A. Derrig, vice president of research for the Insurance Fraud Bureau of Massachusetts, lists several ways that auto-insurance fraud can occur.

Examples of soft auto-insurance fraud can include filing more than one claim for a single injury, filing claims for injuries not related to an automobile accident, misreporting wage losses due to injuries, or reporting higher costs for car repairs than those that were actually paid. Hard auto-insurance fraud can include activities such as staging automobile collisions, filing claims when the claimant was not actually involved in the accident, submitting claims for medical treatments that were not received, or inventing injuries.[19] Hard fraud can also occur when claimants falsely report their vehicle as stolen. Soft fraud accounts for the majority of fraudulent auto-insurance claims.[18]

Another example is that a person may illegally register their car to a location that would net them cheaper insurance rates than where they actually live, sometimes called "rate evasion". For example, some drivers in Brooklyn drive with Pennsylvania license plates because registering their car in a rural part of Pennsylvania will cost a lot less than registering it in Brooklyn. Another form of automobile insurance fraud, known as "fronting," involves registering someone other than the real primary driver of a car as the primary driver of the car. For example, parents might list themselves as the primary driver of their children's vehicles to avoid young driver premiums.

"Crash for cash" scams may involve random unaware strangers, set to appear as the perpetrators of the orchestrated crashes.[20] Such techniques are the classic rear-end shunt (the driver in front suddenly slams on the brakes, eventually with brake lights disabled), the decoy rear-end shunt (when following one car, another one pulls in front of it, causing it to brake sharply, then the first car drives off) or the helpful wave shunt (the driver is waved in to a line of queuing traffic by the scammer who promptly crashes, then denies waving)[21]

Organized crime rings can also be involved in auto-insurance fraud, sometimes carrying out schemes that are very complex. An example of one such ploy is given by Ken Dornstein, author of Accidentally, on Purpose: The Making of a Personal Injury Underworld in America. In this scheme, known as a “swoop-and-squat,” one or more drivers in “swoop” cars force an unsuspecting driver into position behind a “squat” car. This squat car, which is usually filled with several passengers, then slows abruptly, forcing the driver of the chosen car to collide with the squat car. The passengers in the squat car then file a claim with the other driver’s insurance company. This claim often includes bills for medical treatments that were not necessary or not received.[22]

An incident that took place on Golden State Freeway June 17, 1992, brought public attention to the existence of organized crime rings that stage auto accidents for insurance fraud. These schemes generally consist of three different levels. At the top, there are the professionals--doctors or lawyers who diagnose false injuries and/or file fraudulent claims and these earn the bulk of the profits from the fraud. Next are the "cappers" or "runners", the middlemen who obtain the cars to crash, farm out the claims to the professionals at the top, and recruit participants. These participants at the bottom-rung of the scheme are desperate people (poor immigrants or others in need of quick cash) who are paid around $1000 USD to place their bodies in the paths of cars and trucks, playing a kind of Russian roulette with their lives and those of unsuspecting motorists around them. According to investigators, cappers usually hire within their own ethnic groups. What makes busting these staged-accident crime rings difficult is how quickly they move into jurisdictions with lesser enforcement, after a crackdown in a particular region. As a result, in the US several levels of police and the insurance industry have cooperated in forming task forces and sharing databases to track claim histories. [23][24]

In the United Kingdom, there is an increasing incidence of false whiplash claims to car insurance companies from motorists involved in minor car accidents (for instance; a shunt). Because the mechanism of injury is not fully understood, A&E doctors have to rely on a patient's external symptoms (which are easy to fake). Resultingly, "no win no fee" personal injury solicitors exploit this "loophole" for easy compensation money (often a £2500 payout). Ultimately this has resulted in increased motor insurance premiums, which has had the knock-on effect of pricing younger drivers off the road.

Property insurance

Possible motivations for this can include obtaining payment that is worth more than the value of the property destroyed, or to destroy and subsequently receive payment for goods that could not otherwise be sold. According to Alfred Manes, the majority of property insurance crimes involve arson.[25] One reason for this is that any evidence that a fire was started by arson is often destroyed by the fire itself. According to the United States Fire Administration, in the United States there were approximately 31,000 fires caused by arson in 2006, resulting in losses of $755 million.[26] Example: The Moulin Rouge in Las Vegas was struck by arson twice within 6 years.[27]

Council compensation claims

The fraud involving claims from the councils' insurers suppose staging damages blamable on the local authorities (mostly falls and trips on council owned land) or inflating the value of existing damages.[28]

Detecting insurance fraud

The detection of insurance fraud generally occurs in two steps. The first step is to identify suspicious claims that have a higher possibility of being fraudulent. This can be done by computerized statistical analysis or by referrals from claims adjusters or insurance agents. Additionally, the public can provide tips to insurance companies, law enforcement and other organizations regarding suspected, observed, or admitted insurance fraud perpetrated by other individuals. Regardless of the source, the next step is to refer these claims to investigators for further analysis.

Due to the sheer number of claims submitted each day, it would be far too expensive for insurance companies to have employees check each claim for symptoms of fraud.[29] Instead, many companies use computers and statistical analysis to identify suspicious claims for further investigation.[30] There are two main types of statistical analysis tools used: supervised and unsupervised.[29] In both cases, suspicious claims are identified by comparing data about the claim to expected values. The main difference between the two methods is how the expected values are derived.[29]

In a supervised method, expected values are obtained by analyzing records of both fraudulent and non-fraudulent claims.[29] According to Richard J. Bolton and David B. Hand, both of Imperial College in London, this method has some drawbacks as it requires absolutely certainty that those claims analyzed are actually either fraudulent or non-fraudulent, and because it can only be used to detect types of fraud that have been committed and identified before.[29]

Unsupervised methods of statistical detection, on the other hand, involve detecting claims that are abnormal.[29] Both claims adjusters and computers can also be trained to identify “red flags,” or symptoms that in the past have often been associated with fraudulent claims.[31] Statistical detection does not prove that claims are fraudulent; it merely identifies suspicious claims that need to be investigated further.[29]

Fraudulent claims can be one of two types. They can be otherwise legitimate claims that are exaggerated or “built up,” or they can be false claims in which the damages claimed never actually occurred. Once a built up claim is identified, insurance companies usually try to negotiate the claim down to the appropriate amount.[32] Suspicious claims can also be submitted to “special investigative units”, or SIUs, for further investigation. These units generally consist of experienced claims adjusters with special training in investigating fraudulent claims.[33] These investigators look for certain symptoms associated with fraudulent claims, or otherwise look for evidence of falsification of some kind. This evidence can then be used to deny payment of the claims or to prosecute fraudsters if the violation is serious enough.[34]

Determining fraud committed by the health insurance companies can sometimes be found be comparing revenues from premiums paid against the expenditure by the health insurance companies on claims.

As an example, in 2006 the Harris County Medical Society, in Texas, had a health insurance rate increase of 22 percent for “consumer-driven” health plan from Blue Cross and Blue Shield of Texas. This was despite the fact that during the previous year Blue Cross had paid out only 9 percent of the collected premium dollars for claims.[17]

Legislation

National and local governments, especially in the last half of the twentieth century, have recognized insurance fraud as a serious crime, and have made efforts to punish and prevent this practice. Some major developments are listed below:

United States

  • Insurance Fraud is specifically classified as a crime in all states, though a minority of states only criminalize certain types (i.e. Oregon only outlaws Worker Compensation and Property Claim fraud).[8]
  • 19 states require mandatory insurer fraud plans. This requires companies to form programs to combat fraud and in some cases to develop investigation units to detect fraud.[8]
  • 41 states have fraud bureaus. These are law enforcement agencies where “investigators review fraud reports and begin the prosecution process.”[8]
  • Section 1347 of Title 18 of the United States Code states that whoever attempts or carries out a “scheme or artifice” to “defraud a health care benefit program” will be “fined under this title or imprisoned not more than 10 years, or both.” If this scheme results in bodily injury, the violator may be imprisoned up to 20 years, and if the scheme results in death the violator may be imprisoned for life.[35]

Canada

  • The Insurance Crime Prevention Bureau was founded in 1973 to help fight insurance fraud. This organization collects information on insurance fraud, and also carries out investigations. Approximately one third of these investigations result in criminal conviction, one third result in denial of the claim, and one third result in payment of the claim.[36]
  • British Columbia’s Traffic Safety Statutes Amendment Act of 1997 states that any person who submits a motor vehicle insurance claim that contains false or misleading information may on the first offence be fined C$25,000, imprisoned for two years, or both. On the second offense, that person may be fined C$50,000, imprisoned for two years, or both.[37]

United Kingdom

  • A major portion of the Financial Services Act of 1986 was intended to help prevent fraud.[38]
  • The Serious Fraud Office, set up in 1987 under the Criminal Justice Act, was established to “improve the investigation and prosecution of serious and complex fraud.”[38]
  • The Fraud Act 2006 specifically defines fraud as a crime. This act defines fraud as being committed when a person “makes a false representation,” “fails to disclose to another person information which he is under a legal duty to disclose,” or abuses a position in which he or she is “expected to safeguard, or not to act against, the financial interests of another person.” This act also defines the penalties for fraud as imprisonment up to ten years, a fine, or both.[39]

See also

  • Horse murders
  • The Invisible Bankers: Everything the Insurance Industry Never Wanted You to Know (book)
  • Viaene S. & Dedene G. Insurance fraud: issues and challenges. Geneva Papers on Risk and Insurance. 29 (2) : 313 -333, 2004 (article)

Bibliography

  • Bolton, Richard J. and David J. Hand. "Statistical Fraud Detection: A Review." Statistical Science. 17.3 (2002): 235-249.
  • Clarke, Michael. "The Control of Insurance Fraud, A Comparative View." The British Journal of Criminology. 30.1 (1990): 1-23.
  • Coalition Against Insurance Fraud. Annual Report. Washington, DC: Coalition Against Insurance Fraud, 2006.
  • Coalition Against Insurance Fraud. "Insurance Fraud Hall of Shame: Mother Almost Blamed for Son's Arson." 31 12 2006. Coalition Against Insurance Fraud. 13 December 2007.[40]
  • Coalition Against Insurance Fraud. "Learn About Fraud." Coalition Against Insurance Fraud. 1 December 2007.[41]
  • Derrig, Richard A. "Insurance Fraud." The Journal of Risk and Insurance. 69.3 (2002): 271-287.
  • Dornstein, Ken. Accidentally on Purpose: The Making of a Personal Injury Underworld in America. New York: St. Martin's Press, 1996.
  • Feldman, Roger. "An Economic Explanation for Fraud and Abuse in Public Medical Care Programs." The Journal of Legal Studies. 30.2 (2001): 569-577.
  • Ghezzi, Susan Guarino. "A Private Network of Social Control: Insurance Investigative Units." Social Problems. 30.5 (1983): 521-531.
  • Hyman, David A. "Health Care Fraud and Abuse: Market Change, Social Norms, and the Trust 'Reposed in the Workmen'." The Journal of Legal Studies. 30.2 (2001): 531-567.
  • Insurance Information Institute. "Fraud." Insurance Information Institute. 1 December 2007.[42]
  • Insurance Information Institute. "Insurance Fraud." Insurance Information Institute. 1 December 2007.[43]
  • Insurance Information Institute. "No-Fault Insurance Fraud in N.Y. State." Insurance Information Institute. 1 December 2007.[44]
  • Legislative Assembly of British Columbia. "Traffic Safety Statutes Amendment Act." 1997.
  • Manes, Alfred. "Insurance Crimes." Journal of Criminal Law and Criminology 35.1 (1945): 34-42.
  • Ministry of Justice. "Fraud Act 2006." 11 August 2006. The UK Statute Law Database. 13 December 2007.[45]
  • National Health Care Anti-Fraud Association. "The Problem of Health Care Fraud." National Health Care Anti-Fraud Association. 1 December 2007.[46]
  • Office of the Law Revision Counsel, U.S. House of Representatives. "United States Code; Title 18, Section 1347." 2 January 2006.[47]
  • Pontell, Henry N., Paul D. Jesilow and Gilbert Geis. "Policing Physicians: Practitioner Fraud and Abuse in a Government Medical Program." Social Problems. 30.1 (1982): 117-125.
  • Staple, George. "Serious and Complex Fraud: A New Perspective." The Modern Law Review. 56.2 (1993): 127-137.
  • Tennyson, Sharon and Pau Salsas-Forn. "Claims Auditing in Automobile Insurance: Fraud Detection and Deterrence Objectives." The Journal of Risk and Insurance. 69.3 (2002): 289-308.
  • U.S. Fire Administration. "Arson Fire Statistics." 11 October 2007. U.S. Fire Administration. 13 December 2007.[48]
  • United States of America v. Naseem Chaudhry. United States District Court, Northern District of Illinois, Eastern Division. February 2005.
  • Viaene, Stijn, et al. "A Comparison of State-of-the-Art Classification Techniques for Expert Automobile Insurance Claim Fraud Detection." The Journal of Risk and Insurance. 69.3 (2002): 373-421.

References

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  2. ^ Coalition Against Insurance Fraud. Annual Report.
  3. ^ Insurance Information Institute. "Insurance Fraud."
  4. ^ National Health Care Anti-Fraud Association. "The Problem of Health Care Fraud."
  5. ^ Hyman, David A. "Health Care Fraud and Abuse." p. 532.
  6. ^ Insurance Fraud Bureau. "Fighting Organized Insurance Fraud." p. 2.
  7. ^ Insurance Bureau of Canada. "Cost of Personal Injury Fraud."
  8. ^ a b c d e f Insurance Information Institute. "Fraud."
  9. ^ Coalition Against Insurance Fraud. "Learn About Fraud."
  10. ^ Quiggle, James. [1] "Health Fraud" Scam Alerts. Coalition Against Insurance Fraud, 2011
  11. ^ U.S. Attorney's Office (2011-07-26). "Salisbury Cardiologist Convicted of Implanting Unnecessary Cardiac Stents". FBI. http://www.fbi.gov/baltimore/press-releases/2011/salisbury-cardiologist-convicted-of-implanting-unnecessary-cardiac-stents. 
  12. ^ Feldman, Roger. "Economic Explanation." p. 569-570.
  13. ^ Hyman, David A. "Health Care Fraud and Abuse." p. 541.
  14. ^ Hyman, David A. "Health Care Fraud and Abuse." p. 547.
  15. ^ a b Pontell, Henry N., et al. "Policing Physicians." p. 118.
  16. ^ Fried, Joseph P. (2000-08-02). "Metro Business; New York State Fines Insurer $500,000". The New York Times. http://www.nytimes.com/2000/08/02/nyregion/metro-business-new-york-state-fines-insurer-500000.html. 
  17. ^ a b hcfan.3cdn.net
  18. ^ a b Tennyson, Sharon et al. "Claims Auditing" p. 289.
  19. ^ Derrig, Richard A. "Insurance Fraud." p. 274.
  20. ^ "BBC News - Car crash scams at record level |publisher[=Bbc.co.uk". 2010-08-21. http://www.bbc.co.uk/news/uk-11046344. Retrieved 2010-08-21. 
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  22. ^ Dornstein, Ken. Accidentally on Purpose. p. 3.
  23. ^ motherjones.com
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  25. ^ Manes, Alfred. "Insurance Crimes." p. 35.
  26. ^ U.S. Fire Administration. "Arson Fire Statistics."
  27. ^ [2][dead link]
  28. ^ "Housing and Council Tax Benefit fraud - Allerdale Borough Council". Allerdale.gov.uk. 2009-11-02. http://www.allerdale.gov.uk/advice-and-benefits/benefits/housing-benefit/housing-benefit-fraud.aspx. Retrieved 2010-08-21. 
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  30. ^ Derrig, Richard A. "Insurance Fraud." p. 277.
  31. ^ Viaene, Stijn, et al. "Insurance Claim Fraud Detection." p. 375.
  32. ^ Derrig, Richard A. "Insurance Fraud." p. 278.
  33. ^ Viaene, Stijn, et al. "Insurance Claim Fraud Detection." p. 374.
  34. ^ Ghezzi, Susan Guarino. " Private Network."
  35. ^ Office of the Law Revision Counsel, U.S. House of Representatives. "United States Code."
  36. ^ Clarke, Michael. “The Control of Insurance Fraud.” p. 10.
  37. ^ Legislative Assembly of British Columbia. "Traffic Safety Statutes Amendment Act."
  38. ^ a b Staple, George. "Serious and Complex Fraud." p. 127.
  39. ^ Ministry of Justice. "Fraud Act 2006."
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