Insurance fraud has existed since the beginning of insurance as a commercial enterprise.Fraudulent claims account for a significant portion of all claims received by insurers, and cost billions of dollars annually. Types of insurance fraud are 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 affect the lives of innocent people, both directly through accidental or intentional injury or damage, and indirectly as these crimes cause insurance premiums to be higher. Insurance fraud poses a significant problem, and governments and other organizations make efforts to deter such activities.
Causes
The “chief motive in all insurance crimes is financial profit.” Insurance contracts provide both the insured and the insurer with opportunities for exploitation.
According to the Coalition Against Insurance Fraud, the causes vary, but are usually centered on greed, and on holes in the protections against fraud. Often, those who commit insurance fraud view it as a low-risk, lucrative enterprise. For example, drug dealers who have entered insurance fraud think it’s safer and more profitable than working street corners. Compared to those for other crimes, court sentences for insurance fraud can be lenient, reducing the risk of extended punishment. Though insurers try to fight fraud, some will pay suspicious claims anyway; settling such claims is often cheaper than legal action.
Another reason for fraud is over-insurance, when the amount insured is greater than the actual value of the property insured. This condition can be very difficult to avoid, especially since an insurance provider might sometimes encourage it in order to obtain greater profits. 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. The most common form of insurance fraud is inflating the value of the loss.
Insurance companies are also susceptible to fraud because it's possible for fraudsters to file claims for damages that never occurred.
Losses due to insurance fraud
It is hard place an exact value on the money stolen through insurance fraud. Insurance fraud is deliberately 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. 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. 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. 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. Other estimates attribute as much as 10% of the total healthcare spending in the United States to fraud—about $115 billion annually. Another study of all types of fraud committed in the United States insurance institutions (property-and-casualty, business liability, healthcare, social security, etc.)put the true cost at 33% to 38% of the total cash flow through the system. This study resulted in the book title "The Trillion Dollar Insurance Crook" by J.E. Smith. 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. The Insurance Bureau of Canada estimates that personal injury fraud in Canada costs about C$500 million annually. Indiaforensic Center of Studies estimates that Insurance frauds in India costs about $6.25 billion annually.
Hard vs. soft fraud
Insurance fraud can be classified as either hard fraud or soft fraud.
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.
Soft fraud, which is far more common than hard fraud, is sometimes also referred to as opportunistic fraud. This type of fraud consists of policyholders exaggerating otherwise-legitimate claims. For example, when involved in an automotive collision an insured person might claim more damage than actually occurred. Soft fraud can also occur when, while obtaining a new health insurance policy, an individual misreports previous or existing conditions in order to obtain a lower premium on his or her insurance policy.
Types of insurance fraud
Life insurance
Life insurance fraud may involve faking death to claim life insurance. Fraudsters may sometimes turn up a few years after disappearing, claiming a loss of memory.
An example of life insurance fraud is the John Darwin disappearance case, which was an investigation into the act of pseudocide committed by the 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
Health insurance fraud is described as an intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group.
Fraud can be committed either by an insured person or by a provider. Member fraud consists of claims on behalf of ineligible members and or dependents, alterations on enrollment forms, concealing pre-existing conditions, failure to report other coverage, prescription drug fraud, and failure to disclose claims that were a result of a work-related injury.
Provider fraud consists of claims submitted by bogus physicians, billing for services not rendered, billing for higher level of services, diagnosis or treatments that are outside the scope of practice, alterations on claims submissions, and providing services while medical licenses are either suspended or revoked. Independent medical examinations debunk false insurance claims and allow the insurance company or claimant to seek a non-partial medical view for injury-related cases.
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”. 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, rather than that which they rendered.
Another motivation for 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. 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 other physicians 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.
Automobile insurance
Fraud rings or groups may fake traffic deaths or stage collisions to make false insurance or exaggerated claims and collect insurance money. The ring may involve insurance claims adjusters and other people who create phony police reports to process claims.
The Insurance Fraud Bureau in the UK estimated there have already been more than 20,000 staged collisions and false insurance claims across the UK from 1999 to 2006. One tactic fraudsters use is to drive to a busy junction or roundabout and brake sharply causing a motorist to drive into the back of them. They claim the other motorist was at fault because they were driving too fast or too close behind them, and make a false and inflated claim to the motorist's insurer for whiplash and damage which can give the fraudsters up to £30,000. In the Insurance Fraud Bureau's first year or operation, the usage of data mining initiatives exposed insurance fraud networks and led to 74 arrests and a five-to-one return on investment.
Staged collisions
In staged collision fraud, fraudsters use a motor vehicle to stage an accident with the innocent party. Typically, the fraudsters' vehicle carries four or five passengers. Its driver makes an unexpected manoeuvre, forcing an innocent party to collide with the fraudster's vehicle. Each of the fraudsters then files claims for injuries sustained in the vehicle. A “recruited” doctor diagnoses whiplash or other soft-tissue injuries which are hard to dispute later.
Other examples include jumping in front of cars as done in Russia. The driving conditions and roads are dangerous with many people trying to scam drivers by jumping in front of expensive-looking cars or crashing into them. Hit and runs are very common and insurance companies notoriously specialize in denying claims. Two-way insurance coverage is very expensive and almost completely unavailable for vehicles over ten years old–the drivers can only obtain basic liability. Because Russian courts do not like using verbal claims, most people have dashboard cameras installed to warn would-be perpetrators or provide evidence for/against claims.
Exaggerated claims
A real accident may occur, but the dishonest owner may take the opportunity to incorporate a whole range of previous minor damage to the vehicle into the garage bill associated with the real accident. Personal injuries may also be exaggerated, particularly whiplash.
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. 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. For example, the Moulin Rouge Hotel in Las Vegas was struck by arson twice within six years.
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.
See also
- Federal Bureau of Investigation
- Florida Division of Insurance Fraud
- Horse murders
- Split billing
External links
- What is Auto Insurance Fraud and How to Prevent it? Carsnaps.com (this link no longer valid)
- India losing $6.25 billion to Insurance Frauds
- Insurance Information Institute. Insurance Information Institute.
- Coalition Against Insurance Fraud. Coalition Against Insurance Fraud.
- National Health Care Anti-Fraud Association
- National Insurance Crime Bureau. National Insurance Crime Bureau.
- Insurance Bureau of Canada
- UK Insurance Fraud Bureau
- Insurance Research Council
- U.S. Fire Administration. United States Fire Administration.
- 2009 Florida report: Impacts of the Economy and Insurance Fraud
- California: Department of Insurance; Fraud: What is Insurance Fraud?
- UK Insurance Fraud Register
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