Insurance fraud
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Insurance fraud refers to any intentional act committed to deceive or mislead an insurance company during the application or claims process, or the wrongful denial of a legitimate claim by an insurance company. It occurs when a claimant knowingly attempts to obtain a benefit or advantage they are not entitled to receive, or when an insurer knowingly denies a benefit or advantage that is due to the insured. According to the United States Federal Bureau of Investigation, the most common schemes include premium diversion, fee churning, asset diversion, and workers compensation fraud.[1] False insurance claims are insurance claims filed with the fraudulent intention towards an insurance provider.
Fraudulent claims account for a significant portion of all claims received by insurers, and cost billions of dollars annually. Insurance fraud poses a significant problem, and governments and other organizations try to deter such activity.
Studies suggest that the greatest total dollar amount of fraud is committed by the health insurance companies themselves, intentionally not paying claims and deleting them from their systems,[2] and denying and cancelling coverage.[3]
History
[edit]Insurance fraud has existed since the beginning of insurance as a commercial enterprise.[4]
An epigram by the Roman poet Martial provides clear evidence that the phenomenon of insurance fraud was already known in the Roman Empire during the first century AD:[5]
- "Tongilianus, you paid two hundred [denarii] for your house;
- An accident too common in this city destroyed it.
- You collected ten times more. Doesn't it seem, I pray,
- That you set fire to your own house, Tongilianus?"
Book III, No. 52
Causes
[edit]The "chief motive in all insurance crimes is financial profit".[4] Insurance contracts provide both the insured and the insurer with opportunities for exploitation.
According to the American Coalition Against Insurance Fraud, the causes vary, but are usually centered on greed, and on holes in the protections against fraud.[6] Those who commit insurance fraud may view it as a low-risk, lucrative enterprise as compared to other forms of criminal activity.[7]
Losses due to insurance fraud
[edit]As insurance fraud may not be detected, it is difficult to accurately estimate its total cost to society.[4] Among organizations that have estimated its cost, 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.[8] The Insurance Information Institute, insurance fraud accounts for about 10 percent of the property/casualty insurance industry's incurred losses and loss adjustment expenses.[9] 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.[10] According to the FBI, non-health insurance fraud costs an estimated $40 billion per year, which increases the premiums for the average U.S. family between $400 and $700 annually.[1]
Another study of all types of fraud committed in the United States insurance institutions (property-and-casualty, business liability, healthcare, social security, etc.) estimates the 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.[11] The Insurance Bureau of Canada estimates that personal injury fraud in Canada costs about C$500 million annually.[12] Indiaforensic Center of Studies estimates that Insurance frauds in India costs about $6.25 billion annually.[13]
Hard and soft fraud
[edit]Insurance fraud can be classified as either hard fraud or soft fraud.[14]
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[15] in order to claim payment for damages. Criminal rings are sometimes involved in hard fraud schemes that can steal millions of dollars.[16]
Soft fraud, which is far more common than hard fraud, is sometimes also referred to as opportunistic fraud.[14] 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 to obtain a lower premium on the insurance policy.[14]
Types of insurance fraud
[edit]Life insurance
[edit]The majority of life insurance fraud occurs at the application stage, involving applicants misrepresenting their health, their income, and other personal information in order to get a cheaper premium. As more and more insurance amendments can be performed online or over the telephone, identity theft has become an enabling crime that can lead to the amendment of life insurance terms to benefit a fraudster; for example, by adding a second stolen identity as a new beneficiary.[17]
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.[18] For example, in the case of John Darwin, a former teacher and prison office turned up alive five years after he was purported to have died in a canoeing accident, after his family had made a successful claim on his life insurance. Similarly, former British Government minister John Stonehouse reportedly missing in 1974 from a beach in Miami after the acquisition of multiple life insurance policies, but was discovered living under an assumed name in Australia.[19]
Health care insurance
[edit]Health insurance fraud involves an intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group, or being wrongfully denied to a person entitled to receive benefits. Fraud can be committed either by an insured person or by a provider.
Member fraud consists of such acts as the making of claims on behalf of ineligible members or their dependents, making false statements on enrollment forms, concealing preexisting conditions that could affect the scope of coverage or cost of the policy, and failure to disclose claims that were a result of a work-related injury in violation of the terms of a health insurance policy.
Provider fraud consists of claims submitted by medical care providers, and may include billing for services not rendered, billing for higher level of services than those provided, making false statements on claims submissions, double-billing by doctors who charge more than once for the same service, performance of unnecessary medical treatments or surgery,[20] and billing for services other than those actually rendered.[21] Providers may also bill for care actually provided to their patients, but which is not medically necessary. Practices that may be used to perpetrate fraud include "up-coding" or "upgrading", which involve billing for more expensive treatments than those actually provided; "phantom billing", billing for services not rendered; and "ganging", billing for services to family members or other individuals who are accompanying the patient but who did not personally receive any services.[22]
Health insurance fraud depletes the resources of taxpayer-funded programs like Medicare.[23] 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.[22]
It is estimated that in the U.S., as of 2017, $262 billion in healthcare claims are initially denied,[24] and health systems spend approximately $20 billion each year trying to secure payment for valid health insurance claims that were wrongly denied, including some claims that were preapproved by the insurance company.[25] Forms of fraud by health insurance companies include the wrongful denial of claims, wrongful cancellation of coverage, and underpayment of hospitals and physicians.[2][3]
When detected, health insurance fraud can result in civil liability as well as criminal penalties, and potential action against a healthcare provider's license.[26][27]
Automobile insurance
[edit]Automobile insurance fraud occurs when somebody intentionally seeks benefits from an insurance company that they know that they are not legitimately entitled to receive.
The UK Insurance Research Council estimated that in 1996, 21 to 36 percent of auto-insurance claims contained elements of suspected fraud.[28]
Schemes used to defraud automobile insurance providers differ greatly in complexity and severity, and include both individual and organized efforts.[29]
Staged collisions
[edit]Fraud rings or groups may fake traffic deaths or stage collisions to make false insurance or exaggerated claims and collect insurance money.[30] The fraud may involve the engineering of a deliberate collision with the innocent driver of another vehicle.[31] Some fraud rings involve insurance claims adjusters who authorize payment on the claims.[32] In the UK, the Association of Chief Police Officers estimated that 30,000 auto accidents were staged in 2009.[33] Insurance fraud may also include such actions as a pedestrian jumping in front of a car, then seeking compensation for claimed injuries.[34]
Staged collision schemes may involve fraud at three different levels. At the top, there are lawyers who file fraudulent claims, supported by doctors who fabricate or exaggerate diagnoses and treatment records. 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. At the bottom are the participants recruited to risk injury in the staged accidents. These rings may involve organized crime.[35][36]
Exaggerated claims
[edit]After a motor vehicle collision, a vehicle owner may attempt to make a claim for coverage beyond the scope of what was caused by the accident, for example by seeking coverage for preexisting damage.[37] Physical injuries may also be exaggerated by a driver or other person claiming injury in a collision.[38][39]
False reports of theft
[edit]Insurance fraud occurs when an insured party falsely report their vehicle as stolen.
Rate evasion
[edit]In rate evasion, a vehicle owner registers a vehicle to a location where the insurer offers lower rates as compared to where they actually reside.
Another form of fraud, known as "fronting", involves registering someone other than the real primary driver of a car as the primary driver of the car in order to obtain a lower rate. For example, parents might list themselves as the primary driver of their children's vehicles to avoid young driver premiums.
Property insurance
[edit]Possible motivations for property insurance fraud 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 fraudulent property insurance crimes involve arson.[40] 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.[41]
Another basis for fraud is over-insurance, in which someone insures property for more than its real value.[4] This condition can be difficult to avoid, especially since an insurance provider might sometimes encourage it to obtain greater profits.[4] This lets fraudsters profit by destroying their property, because they receive an insurance payout greater that the value of the property. The most common forms of insurance fraud are re-framing a non-insured damage to make it an event covered by insurance, and inflating the value of the loss.[42]
Unemployment insurance
[edit]Unemployment insurance fraud can occur when someone who is not unemployed or who steals the identity of another individual obtains unemployment benefits to which he or she is not entitled. During 2020, there was a significant spike of unemployment fraud in the United States.[43]
Premium fraud
[edit]In addition to fraudulent claims, insurers can lose premium because customers inaccurately describe the risk, causing less premium to be charged. This can happen for any type of insurable risk and is most noteworthy in workers compensation insurance, where insureds report fewer employees, less payroll, and less risky employees than is actually intended to be covered by the policy.[44]
Council compensation claims
[edit]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.[45]
Detecting insurance fraud
[edit]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, members of 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.[46] Instead, many companies use computers and statistical analysis to identify suspicious claims for further investigation.[47] There are two main types of statistical analysis tools used: supervised and unsupervised.[46] In either case, 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.[46]
In a supervised method, expected values are obtained by analyzing records of both fraudulent and non-fraudulent claims.[46] According to Richard J. Bolton and David B. Hand, both of Imperial College London, this method has some drawbacks as it requires absolute 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.[46]
Unsupervised methods of statistical detection, on the other hand, involve detecting claims that are abnormal.[46] 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.[48] Statistical detection does not prove that claims are fraudulent; it merely identifies suspicious claims that must be investigated further.[46]
Fraudulent claims can be one of two types:[49]
- 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.[50] 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.[51] 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.[52]
When an insurance company's fraud department investigates a fraud claim, they frequently proceed in two stages: pre-contact and post-contact.[53] In the pre-contact stage they analyze all available evidence before they contact the suspect. They may review submitted paperwork, reach out to third parties, and gather evidence from available sources. Then, in the "post-contact" stage, they interview the suspect to gather more information and, ideally, obtain an incriminating statement. Insurance fraud investigators are trained to question the suspect in a way that precludes the suspect raising a valid defense at a later time. For example, questions about access to claim forms preclude the defense of another individual filling out the fraudulent documents. Common defenses that the suspect interview may preclude include the suspect lacking either the knowledge that their statement was false[54] or the intention to defraud,[55] or the suspect making an ambiguous statement that was later misinterpreted.[56] Full disclosure may add credibility to a suspect's account of events, but omissions from disclosure or false statements may detract from the suspect's credibility in later interviews or proceedings.[56]
Within the context of health insurance, fraud by health insurance companies is sometimes found by comparing revenues from premiums paid against the expenditure by the health insurance companies on claims. For example, in 2006 the Harris County Medical Society, in Texas, had a health insurance rate increase of 22 percent for "consumer-driven" health plans 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.[3]
National legislation and practice on insurance fraud
[edit]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 by jurisdiction:
United States
[edit]- Insurance Fraud is specifically classified as a crime in all states, although a minority of states only criminalize certain types (e.g. Oregon only outlaws Worker Compensation and Property Claim fraud).[14]
- 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.[48]
- 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.[14]
- 41 states have fraud bureaus. These are law enforcement agencies where "investigators review fraud reports and begin the prosecution process".[14]
- 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 a 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.[57]
Besides making laws more severe, legislation[clarification needed] has also come up with a list for management that should be implemented so that companies are better suited to combat the possibility of being scammed. That list includes:
- Understanding that fraud does exist and that there is a high possibility for it happening.
- Being fully aware of the dangers and severity of the problem.
- Understanding the importance of the hiring process and how important it is to hire honest individuals.
- Learn to deal with the economic side of business. That means putting procedures and policies in place to catch and deal with individuals trying to commit fraud.[58]
Canada
[edit]- 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.[59]
- 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.[60]
United Kingdom
[edit]- A major portion of the Financial Services Act 1986 was intended to help prevent fraud.[61]
- The Serious Fraud Office, set up under the Criminal Justice Act 1987, was established to "improve the investigation and prosecution of serious and complex fraud."[61]
- 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 a person 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.[62]
- The City of London Police runs an Insurance Fraud Enforcement Department, which specializes in tracking criminals who knowingly commit insurance fraud.[63]
- The common law holds that fraudulent claims need not be paid and that insurance premiums paid are forfeited: this "fraudulent claims rule" was incorporated into statute law by section 12(1) of the Insurance Act 2015:
- Where the insured commits a fraud against the insurer, the insurer is not liable to pay the insurance claim to which the fraud relates.
- Where the insurer has already paid out insurance monies on the claim and later discovers the fraud, the insurer may recover those monies from the insured.
- The insurer may also treat the insurance contract as if it had been terminated at the time of the "fraudulent act". This is dependent on the insurer giving notice of their election to do so to the insured.[64]
See also
[edit]- Federal Bureau of Investigation
- Florida Division of Insurance Fraud
- Show jumping horse killings
- Split billing
- United States Postal Inspection Service
- Anti-fraud
References
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External links
[edit]- 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