The principle function of an insurance investigation is to verify all facts within a claim that is believed to be false or inflated. In addition to diligent fact-finding and comprehensive cross-referencing, insurance investigations also require a fierce independence and objectivity in pursuit of the unvarnished truth. The investigator for the job must not only have diverse experience in insurance claims, but must also be a third-party with no stake in the outcome of the investigation. As insurance claims continue to be on the rise the demand for these third-party insurance investigators will only continue to grow.
The most recent study from Global Insurance Investigations Market by AMA Research has predicted an uptick in insurance investigations between now and 2027. The market study included millions of datapoints, proving to be a comprehensive tool for industry experts and professionals as they attempt to understand the market trends forming of late. However, the question becomes how will the industry will be able to handle the influx of complex insurance investigations without over-taxing their internal resources and operations?
Third-party insurance investigators are always a safe bet when investigating allegedly inflated or fraudulent cases. They have no allegiance to either the insurance company or the claimant, so their findings will stand up to a higher degree of scrutiny in court. If the findings are challenged in a civil court by the claimant, it will be harder to impeach the findings by claiming some sort of bias in the investigation. Third-party insurance investigators, like private investigators are also autonomous in their work, and can operate without the red tape of internal hierarchy or bureaucracy, meaning investigations can move more swiftly as evidence is gathered, processed, and cross-referenced. Their autonomy means they can go where the case takes them in an expedient manner—they can speak to witnesses and gather evidence that may have otherwise been lost while internal boxes were being checked. At the end, not only will there be comprehensive reports to review by the insurance provider, but there is also an independent witness who can speak to the findings first hand, if necessary.
If your firm is having difficulty fielding the influx of insurance fraud investigations, consider the services of Lauth Investigations International to supplement your investigation needs. We carry a glowing A+ rating with the Better Business Bureau, and regularly receive glowing testimonials on our accuracy and professionalism from grateful clients. If you want to learn more, you can call 317-951-1100 for a free quote on how we can help you with insurance investigations, or visit us online at www.lauthinveststg.wpengine.com.
Private investigators have a cultural reputation for many things—surveillance, infidelity, undercover operations—the exciting things we’re used to seeing in movies and television. Many people are unaware that private investigators also take a huge piece of their corporate pie from insurance investigation. Private investigators use their unique skillsets and experiences to pursue the truth in insurance claims to establish their merit and prevent insurance fraud.
There are many ways to commit insurance fraud. For example,
a homeowner might remove property from their home and then report it as stolen.
They might deliberately cause damage to their property and then report a freak
occurrence, or weather, as the culprit. When a suspect claim comes across a
processor’s desk, they can hand it over to a private investigator to perform
due-diligence and vet the claim.
Private investigators can use their famed surveillance
methodology to track the homeowner to a secure location where “stolen” property
is being stored. They could use their access to verified databases to look at
an individual’s various histories, such as criminal, transience, and
litigation. All relevant information is compiled and generated in the form of a
comprehensive report in which the private investigator provides clear
recommendations regarding the validity of the claim.
Sometimes insurance companies only want the private
investigator to take pictures of an accident site, or an injury, or maybe they
just want some spot-check surveillance on an employee claiming worker’s
compensation. Another way insurance companies can rely on private investigators
is with document review. Private investigators can comb repair receipts,
financial records, police reports, and social media for evidence the claim is
fraudulent.
Some insurance companies rely on their own internal investigators to vet and process their claims. It may be more cost-effective to keep the investigation in-house, or leadership might be more comfortable using an internal investigator. The inherent problem with any internal investigation is that any investigating agents who have a stake—direct or otherwise—in the insurance company cannot be completely objective. In an industry where litigation is not only possible, but likely, insurers and guarantors of benefits must be sure their investigations are comprehensive and will hold up to scrutiny.
A common unforeseen issue with handling insurance claim
investigations internally is that it has the potential to slow down daily
operations. Claims gather and bottle-neck at the choke point in the process,
causing employees to feel overwhelmed and increasing their margin of error,
which may result in more lost time and resources correcting those errors. One of
the greatest advantages of hiring a private investigator to vet insurance
claims is their valuable autonomy. They have their own databases, their own
league of investigators, and their own processes. The investigations process
can move quickly because there is very rarely a chain of command and little
bureaucracy involved, leading to more closed claims and greater success for the
company.
Contracting due-diligence out to private investigators means
less stress on internal employees and another layer of credibility for the
investigation. Whether as a replacement for an internal team or on a
case-by-case basis, private investigators can give insurance providers the
valuable information and expertise they need to close cases swiftly and
effectively.
FMLA fraud can devastate a company, but companies should protect the integrity of their investigations to protect themselves.
The Family and Medical Leave Act (FMLA) provides working families balance to their lives when their circumstances take a turn. Whether it’s caring for new life in the household—such as a newborn or a foster child—or to care for an ailing relative, the 1993 act protects employees from being terminated from their jobs when they must take an extended absence for a specific set of reasons. However, abuses of FMLA are extremely common in the American workforce. While suspicions of FMLA abuse should be taken seriously by employers, companies must conduct thorough and unbiased investigations before terminating any employees. Businesses who do not follow protocol can open themselves up to expensive litigation.
In addition to protecting employees from termination during an extended leave, FMLA also requires their various insurance coverage remain in effect. This protection can be guaranteed for up to 12 weeks. According to the Department of Labor:
FMLA is designed to help employees balance their work and family responsibilities by allowing them to take reasonable unpaid leave for certain family and medical reasons. It also seeks to accommodate the legitimate interests of employers and promote equal employment opportunity for men and women.
FMLA applies to all public agencies, all public and private elementary and secondary schools, and companies with 50 or more employees. These employers must provide an eligible employee with up to 12 weeks of unpaid leave each year for any of the following reasons:
the birth and care of the newborn child of an employee;
placement with the employee of a child for adoption or foster care;
to care for an immediate family member (spouse, child, or parent) with a serious health condition; or
medical leave when the employee is unable to work because of a serious health condition.
The use of FMLA within these guidelines (with some exceptions) is designed to protect hard-working men and women from losing their jobs when their family suddenly requires their attention. Life can change so fast, and employees can rest easy knowing their jobs will be waiting for them when they are able to return in top-performing condition.
According to Charlie Plumb, an attorney who represents clients in all phases of management, abuse of this protection should be investigated, provided the employer has an “honest suspicion.” He goes on to say, “This honest suspicion standard is really intended to protect the employer against a claim they are interfering against FMLA leave and/or being retaliatory.”
A familiar scenario is one where an employee has been granted leave under FMLA for a serious illness or injury. The employer then happens to see posts from the employee on social media having fun out with friends, exercising, or driving. The employer might think, “If they’re well enough to do these things, they must be well enough to work.” While this might sound like an open and shut case from the employer’s point of view, Allen Smith of The Society of Human Resources Management, provides an example where this philosophy proved problematic:
“Joan Casciari, an attorney with Seyfarth Shaw in Chicago, said she handled a case that involved an employee who was put on FMLA leave for depression. The employer later discovered, through surveillance, she was doing Christmas shopping with her family and having a wonderful time. But her doctor confirmed “retail therapy” was consistent with her condition and the fact she could shop did not mean she did not require FMLA leave.”
Luckily for the employer in this anecdote, they did their due diligence and consulted a medical professional who could corroborate the circumstances of her FMLA qualifications. Some employers are far hastier. When employers do not conduct comprehensive and objective investigations into suspicious FMLA claims, they can open themselves up to lawsuits that can be devastatingly expensive and a public relations nightmare.
Vigilance of adherence to the guidelines of FMLA becomes manageable when Human Resource directors keep an eye out for certain patterns of behavior, such as absence patterns, especially when they coincide with non-work events (holidays or something personal that they may have mentioned in the past). Employers should also be suspicious of absences directly contradicting any medical certification in frequency or duration.
Once an employer has a reasonable suspicion of FMLA abuse, they should most certainly investigate. However, internal investigations into these kinds of abuses can be very messy for Human Resources and upper management. The aforementioned scenario involving “retail therapy” could have been a disaster if the company had not done their due diligence. Some employers are not so diligent.
Another scenario involving a maintenance worker at a nursing home and rehabilitation center panned out much differently. The employee in question noticed his superior was exhibiting a pattern of absence he found suspicious. He began reviewing surveillance footage to compare to his own personal log of her comings and goings in order to prove she was abusing company time. After discovering the independent investigation, the superior served a series of performance adjustments to the employee before terminating him. The termination came after the employee had submitted an FMLA request. The court found the dates of his termination tied in too closely with his request for FMLA, allowing the employee to take the case to trial.
Scenarios like these are why Human Resources and management should 1) be vigilant of FMLA abuse, and 2) conduct a thorough and unbiased investigation in order to ensure the company is protected from litigation. Many companies choose to handle investigations internally in order to minimize the amount of exposure. However, internal investigations spearheaded by current members of staff, will not only disrupt daily operations, but can also have negative effects like the case of the nursing home. The employee conducting his own investigation may have had honest suspicions of his superior’s misconduct, but he was certainly not a unbiased source to investigate.
Private investigators are probative routes often overlooked when a company has an internal investigation. There are many circumstances under which companies do not want to give up control over an internal investigation, and a private investigator is the definition of a third-party. However, the objectivity of a private investigator is the number one reason why companies should consider them as an option. The personal biases of the persons involved in the previous examples caused the investigation to go south. As an independent contractor, a private investigator’s only loyalty is to the truth. They are vital to ensuring an investigation is a transparent expedition for the truth. This goes a long way towards protecting a business from subsequent lawsuits or bad press.
When handling an investigation internally, employers are limited to what surveillance they can attain from their own equipment or social media. Private investigators are licensed to track individuals and photograph their activity in public. Persons who fraudulently claim to be out for injury can be photographed doing tasks directly contradicting their FMLA claim, like yardwork or lifting heavy groceries. In addition to tracking their public movements, private investigators may also conduct undercover operations in order to investigate any frauds. They are invaluable in this regard as they are not known to those within the company. Whether you’re looking for an FMLA weekender or an FMLA moonlighter, if someone has made a fraudulent FMLA claim, a private investigator is the most-equipped professional to prove or disprove the suspicion.
