The dictionary defines fraud as the intentional perversion of truth to induce another to part with something of value or to surrender a legal right. Insurance fraud can be "hard" or "soft." Hard fraud occurs when someone deliberately fabricates claims or fakes an accident. Criminals are using increasingly sophisticated electronic schemes to defraud insurance companies.
Soft insurance fraud, also known as opportunistic fraud, occurs when normally honest people pad legitimate claims or intentionally understate the number of miles they drive each year or, in the case of business owners, list fewer employees or misrepresent the work they do to get a lower premium.
Those who commit insurance fraud range from organized criminals who steal large sums through fraudulent business activities and insurance claim mills to professionals and technicians who inflate the cost of services or charge for services not rendered, to ordinary people who want to cover their deductible or view filing a claim as an opportunity to make a little money.
Some lines of insurance are more vulnerable to fraud than others. Health care, workers compensation and auto insurance are believed to be the sectors most affected.
Insurance Fraud classifies as a Felony: Insurance fraud is specifically declared unlawful in the state's penal code. A fraudulent act is committed if information in insurance applications is falsified in an attempt to obtain lower premium rates, or to inflate the amount of loss in a claim. Defining the crime specifically helps educate law enforcers about insurance fraud and provides prosecutors with clear-cut cases. Raising the level of the crime from a misdemeanor to a felony not only increases the penalties but also acts as a deterrent to future crimes.
Investigators have used pretexts to obtain information for quite some time. When used correctly, it is an effective investigative technique for gathering difficult information, which might otherwise be unattainable. Before utilizing pretext, EPIS investigators conducting insurance investigations be consider pursuing available public records and conducting Internet and database searches, as they may produce useful information about a claimant's daily activities, business or self-employment activities, published financial information, education, hobbies and any limitation and restrictions relative to lifestyle. Pretexting may be unnecessary at times.
Our Los Angeles investigator's performing work for insurance companies potentially expose themselves and their clients to financial liability when utilizing pretext techniques. EPIS will always check with the carrier or the insurance clients prior to utilizing pretext in an investigation to ascertain whether they have a pretext policy and to obtain their permission.
Not all pretexts are the same. Consider the difference between first party and third party pretexts. In a first party pretext our Los Angeles investigator attempts to obtain information directly from the subject. In this type of pretext the risk is considerably low because there is no third party involved. In the third party pretext, the Los Angeles investigator calls someone familiar with the subject and attempts to obtain information about the subject.