Fraudulent claims account for a significant portion of all claims received by insurers. Insurance crimes concerning personal injury or disability claimants, range in severity from exaggerating injuries to deliberately causing accidents. Fraudulent claimants try to gain financial advantage by false suggestions, faking injuries and disorders, and disguising or concealing the truth.
Experienced examiners have learned to identify indicators of suspicious claims and are equipped with strategies on how to establish the real facts. In difficult cases their investigation and final report could benefit from an investigative psychological evaluation of the claim and an indirect assessment of the claimant.
The most common form of insurance fraud is opportunistic - the exaggeration of a genuine personal claim. A real accident occurs, but the dishonest claimant takes the opportunity to make exaggerated bodily or psychological injury claims. Independent medical experts will provide professional medical assessments, but they often do not have the forensic expertise or experience to detect signs of deception and manipulation. Sometimes medical practitioners fail to use multiple sources of information or do not explore the facts and evidence behind the symptoms that the claimant says he or she is experiencing.
Malingering in the context of insurance claimants is the act of conscious, gross exaggeration of symptoms or impairment to obtain financial compensation. Claimants are sometimes skilled in simulating the symptoms of, for example, post-traumatic stress disorder or depression as a result of an accident. Malingering has been estimated to occur in up to 33% of disability claimants.
A false accusation of, say, sexual harassment in the workplace has a ripple effect that spreads beyond just the accuser and the accused. It has the potential to result in negative morale and insecurity amongst other workers, leaving management with serious difficulties. Problems are exacerbated if management act prior to establishing all of the facts available. Severe injury to the reputation and emotional state of the accused is often underestimated and a claim for false harassment can lead to substantive damages. For instance, the falsely accused employee may lose wages, promotion or even their career. A company can be held liable if it can be shown that their management mishandled the situation.
Insurance examiners can benefit from a psychologically based investigation of the claim. This meticulously assesses both the circumstances surrounding the claim and the nature of the psychological disorder that is claimed. An evaluation of the statement reliability and any evidence of malingering is provided, as well as practical suggestions for further investigation. This may include interview advice (when interviewing the claimant), questions to put to witnesses or other sources of information, directions for a second medical opinion or an additional medical or psychological evaluation.
In cases where false accusation is suspected we offer a professional judgement of the claim. Our evaluation is aimed at pointing out indicators of deceit and unreliability, and providing a description of the motivations of the claimant. This assessment allows us to prescribe tailor-made management procedures and an effective response to the claimant, focusing on damage control and prevention of further escalation or recurrence.