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FraudChronicles.com 3: The Wicked Witch of Insurance Fraud

Appearances can be deceiving. Some older lady may remind you of your grandmother, that is, until she starts filing fraudulent insurance claims. At that point, the proper action is not to throw water on her, but to document the fraud and turn it over to the insurance company and the authorities.

Some are doing something about fraud. FraudChronicles.com (http://www.fraudchronicles.com) sponsored by independent investigators David Morse & Associates, gives information and resources on how to fight insurance fraud. The site also features stories of successful investigations that have resulted in the bust of a fraud perpetrator. And when a fraud perpetrator is busted, that helps everyone, because it helps to bring insurance premiums down.

This is a case from the David Morse & Associates investigations archives, Part 3 of the Fraud Chronicles.

Kindly Old Lady… or The Wicked Witch of Insurance Fraud?
By Jim Smith,
Deputy Director, David Morse & Associates

"Ladies of a certain age come in all varieties, as do 20-somethings and 30-somethings. The baby boom generation of ladies, like all generations of women and men alike, includes the good, the bad and the ethically challenged.

"My inclination is to give little old ladies the benefit of the doubt, having had a very kindly grandmother who was good for cookies, cake and the occasional dollar bill slipped into my pocket when Mom wasn't looking. However, if "grandmother" is the cover and distraction used to get away with a fraudulent claim that comes my way, my fondness for my grandma isn't going to help you. If your claim is bogus, I will bust you.

"The claimant in this case was a little old lady, who said she had gotten injured on the job, and had lost ALL use of her right arm. She couldn't use her hand or fingers, and couldn't even drive.

"It began as a normal investigation. But this 'sweet little old lady' could not stick with the disguise. On first contact, she became quite nasty (without provocation), refused to meet with me and immediately obtained the services of an attorney. Of course this was immediately reported to the insurance company examiner.

"Not a cookies-and-milk type apparently.

"During the course of taking statements, it became quite clear to me that there was something wrong with the employee's allegations. She had been a 'problem' employee, with pending discipline, and there was no report or evidence of a work related injury. Since the initial investigation indicated there was something funny about her allegations, we suggested surveillance be conducted, and this was authorized. We set up surveillance at the claimant's residence.

"The holiday season was just beginning as we undertook the assignment. And our little old lady was fully into her grandmother role. She drove her vehicle, shopped, carried packages, presents and groceries. She picked up and carried small grandkids. We got film of her unscrewing those kid-proof baby bottle tops that are so challenging for most adults.

"Only one problem with this heart-warming scene - she was using her right arm and hand fully and without any limitation, contrary to the assertions on her claim forms and those of her doctor.

"To underscore the 'knowing' element of fraud (as opposed to accidentally making a misstatement), our subject had two medical appointments during this period. She was driven to these medical appointments by another woman, and arrived with her arm in a sling. At each appointment she maintained her original assertion that she was unable to use her right arm, and had to keep it in a sling. However, within 5 minutes of each medical appointment, film was obtained of our subject taking off the sling and taking over as the driver of the vehicle.

"I don't like fraud or the people who commit it. It's why I am good at my job. Grandmother or gangster, executive or laborer - if you lie about injuries in order to collect insurance payments and I get the case, you will be busted. We may not always have enough for prosecution, but in this case we did. This file and evidence were forwarded to the DA and the preliminary hearing has been completed. The judge has determined that the case should go forward to a jury trial, which will commence shortly."

Another victory for truth, justice, and lower insurance premiums.


About the Author: Tom Reitze is President of David Morse & Associates (http://www.davidmorse.com), sponsor of FraudChronicles.com (http://www.fraudchronicles.com). David Morse & Associates is an independent investigations and claims adjusting company with 45 branches in 15 states.




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