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Short History of Antifraud Efforts |
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Short
History of Antifraud Efforts: Fraud in
insurance has undoubtedly existed since the industry's beginnings in the
seventeenth century, but it received little attention until the 1980s because
law enforcement agencies had other priorities and were reluctant to provide the
training needed to investigate and prosecute cases of insurance fraud. And,
given the fine line between investigating suspicious claims and harassing
legitimate claimants, some insurers were afraid that a concerted effort to
eradicate fraud might be perceived as an ant consumer move. In addition, the
need to comply with the time requirements for paying claims imposed by fair
claim practice regulations in many states made it difficult to adequately
investigate suspicious claims.
But by the mid-1980s the rising price of insurance, particularly auto and
health insurance, together with the growth in fraud committed by organized
criminals, prompted many insurers to reexamine the issue. Gradually, insurers
began to see the benefit of strengthening antifraud laws and more stringent
enforcement as a means of controlling escalating costs - a pro-consumer move -
and they found ready allies among those who been adversely affected by fraud.
These included consumers, who were paying for fraud through their insurance premiums;
the people used by organized fraud groups to file false claims, often the poor,
who sometimes found themselves on the wrong side of the law; and chiropractors
and other medical professionals who were concerned that their reputation as a
group was being tarnished by organized fraud ringleaders who had recruited
their members to make fraudulent claims for treatment.
In
their fight against fraud, insurers have also been hampered by public
attitudes. Ongoing studies by the Insurance Research Council show that
significant numbers of Americans think it is all right to inflate their
insurance claims to make up for all the insurance premiums they have paid in
previous years when they have had no claims, or to pad a claim to make up for
the deductible they would have to pay. In addition, insurance fraud must
compete with violent and large-scale white collar crime for prosecutors'
attention and resources. Prosecutors commonly use a dollar threshold before
they will allot resources to trying fraud cases without investigating the
merits of a case.
Antifraud activity on the part of state fraud bureaus and SIUs (special
investigative units within insurance companies) increased in the 1990s.
Heightened antifraud activity along with growth in funding for fraud-fighting
personnel resulted in increased prosecutions. Successful prosecution not only
blocks future fraudulent activities by individuals who are repeat offenders,
but news of prosecutions also acts as a deterrent to others who may be
contemplating committing fraudulent acts.
While the focus initially was on auto insurance fraud, antifraud efforts also
encompass workers compensation fraud, where investigations are directed toward
employers who, to obtain a lower premium, misrepresent their payroll or the
type of work carried out by their employees. These two factors impact premiums.
Payroll is important because workers compensation insurance provides for lost
wages and insurers need to know the maximum they would have to pay if all
employees were injured in the same accident; the type of work carried out by
the firm affects the likelihood of injuries. Workers that use cutting tools,
for example, are more likely to get injured on the job than office workers.
Some employers also apply for coverage under different names to foil attempts
to recover monies owed on previous policies or to avoid detection of their poor
claim record, which would put them in a higher rating category. Medical care
abuse is also a problem. Some medical care providers "up code" -
exaggerate treatment provided to injured workers. Claimants may also abuse the
system by over-utilizing medical care to keep receiving lost income (indemnity)
benefits.
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