Insurers' Antifraud Measures

Insurance companies are not law enforcement agencies. They can only identify suspicious claims, withhold payment where fraud is suspected and to justify their actions by collecting the necessary evidence to use in a court. The success of the battle against insurance fraud therefore depends on two elements: the resources devoted by the insurance industry itself to detecting fraud and the level of priority assigned by legislators, regulators, law enforcement agencies and society as a whole to eradicating it.

A Pasadena, CA based insurance company received a Workers Compensation Claim from their policyholder. The claim involved an employee who allegedly slipped and fell at work, injuring his low back, neck and right shoulder. The employer received numerous complaints from co-workers indicating that the subject was not injured, and was busy with other activities. EPIS, Workers Compensation Fraud team, was asked to verify this information. Our skilled investigators obtained detailed videotape of the subject lifting lumber, playing baseball, and also working privately as a handy man. With successful results, our client denied the employee's benefits, and the case was settled for no monetary value.