Chapter 1 recap: insurance fraud 101

Car insurance fraud is any deception committed against an insurance company for financial gain.
Fraud is illegal in all 50 states, and insurance companies (like ours) do all we can to investigate
and expose fraudsters.

Chapter 2 5 ways car insurance fraud can happen

Chapter 3 1. Vehicle dumping, aka "owner give-up"
This type of car insurance fraud occurs when the owner disposes of the vehicle by leaving it
somewhere, burning it, dumping it in a lake, or even selling it, and then claiming it was stolen.
In situations where the car was sold before being reported stolen, the fraud is intended to pay in 2
ways: through an insurance settlement to replace the stolen vehicle and through the sale of the
original car.

Chapter 4 2. False registration

Where you live affects what you pay for car insurance, and this car insurance scam is designed to
mislead insurers and avoid higher premiums.
Drivers who partake in this scam often live in expensive parts of the country or in neighborhoods
with higher theft rates, so they register their cars in other states or counties where insurance
premiums can be lower.

Chapter 5 3. Exaggerated repair costs after a car accident

This one is committed by less-than-upstanding repair shops. Let's say you bring your car to the
shop after an accident, and the mechanics use shoddy parts to make the necessary repairs. By
repairing your car with cheaper, possibly unsafe parts and billing your car insurance company for
new parts they never used or work they never performed, they're committing fraud for financial
gain.
Body shops can also commit exaggerated repair cost fraud by overcharging an insurer (and a
customer) for necessary repairs. By purposely overstating the accident damages, the shop can
make money after unneeded repairs.

Chapter 6 4. Faulty airbag replacement

This is another type of car repair scam. It happens when mechanics don't replace the airbag after
an accident. Instead, they stuff the compartment with other objects, such as beer cans (yup, you
read that right) or packing peanuts to keep the sensors working.

Some states, like California, passed protective laws regarding airbag replacement. Replacing an
airbag with a fraudulent one can be penalized by a year in prison and up to $5,000 in fines.

Chapter 7 5. Faulty windshield replacement

Windshield fraud can take unsuspecting drivers by surprise. Usually, someone claiming to be a
windshield repair specialist will approach you in a parking lot, trying to convince you that your
windshield is damaged and you need a new one ASAP. But good news: you're in luck because
this friendly expert just so happens to have your type of windshield on hand. And it gets better
because this service will be completely covered by your insurance company. Yep, you won't even
have to pay a dime. You better take advantage of this now, right?
Wrong. This is a scam that may drive up your car insurance rates and possibly put you in danger.
These people aren't the real deal and will most likely replace your perfectly fine windshield with
a shabby one. You might even lose your car insurance coverage if you fall for this type of
scheme, especially if this "specialist" uses your insurance information to submit several
windshield replacement claims under your name.

Chapter 8 protect yourself with our e-star direct repair

program
These repair scams may leave you wondering about a shop's trustworthiness. Our E-star program
is designed to alleviate the worry. As an Esurance customer, you can choose from a sizable list of
highly qualified body shops to repair your car after an accident. And if you go with an Esuranceapproved repair facility, the repair is guaranteed for as long as you own the car.

Chapter 9 fighting fraud

Car insurance fraud is a serious and potentially dangerous criminal offense. If you suspect you've
seen fraud, get in touch with your state's Department of Insurance. And let your insurer know if
you suspect you're the victim of fraud.
Car insurance fraud affects all drivers because insurance companies determine rates, in part,
based on losses. So the more losses (or claims filed) in a city or state, the higher premiums might
be. And car insurance fraud costs drivers billions of dollars in any given year.
We'll fill you in on the basics of car insurance fraud, including the different types of fraud, and
we'll explain how the Esurance Special Investigations Unit (SIU) gets to the bottom of
questionable claims.
If you think you're the victim of car insurance fraud, email us at [email protected].

Chapter 10 what is car insurance fraud?

Car insurance fraud happens when someone deceives an auto insurance company for financial
gain. This can include anything from staged pile-ups to relatively minor fibs about extra damage
after an accident.

Chapter 11 how is car insurance fraud committed?

Car insurance fraud can range from seemingly small omissions and exaggerations to obvious
deceptions. Here are a handful of examples:

Providing incorrect info while getting a quote

Buying a policy after an incident has occurred

Filing more than one claim for a single injury

Filing a claim for injuries unrelated to the accident

Misreporting wages lost due to accident-related injuries

Reporting higher repair costs than those actually paid to the mechanic

Staging a car accident

Filing a claim for a car accident the person wasn't involved in

Submitting a claim for medical treatment that wasn't received

Falsely reporting a vehicle as stolen

Registering a car in a different state for cheaper rates

Chapter 12 esurances special investigations unit

It probably goes without saying that we're committed to fighting car insurance fraud on behalf of
our policyholders. That's why we have a department dedicated to keeping fraud at bay. Our
Special Investigations Unit investigates and pursues eyebrow-raising activity and refers all
suspicious cases of fraud to law enforcement agencies.
Detecting fraud and avoiding fraudulent payouts isn't just good for insurance companies. It's also
good for you, the customer, because you won't have to help shoulder the burden of higher claims
payouts.

Chapter 13 how to report car insurance fraud

Now that you know what car insurance fraud is, consider yourself an honorary member of our
SIU team. By reporting anything suspicious, you'll help keep premiums low for all drivers.
If you suspect someone has filed a fraudulent claim with Esurance, or that you've been
victimized by fraud, email us at [email protected].
Chapter 14 Related links
Staged accidents and how to spot them
Peek into the fraudster's world with this look at commonly staged crashes.
The Coalition Against Insurance Fraud
Find out about current trends in fraud and what's being done to stop them.

Chapter 15 our insurance products

Car insurance

Motorcycle insurance

Renters insurance

Homeowners insurance

Condo insurance

Health insurance

Life insurance

All products

Chapter 16 o

Chapter 17 Insurance fraud

From Wikipedia, the free encyclopedia

Criminal law
Elements

Actus reus

Mens rea

Causation

Concurrence

Scope of criminal liability

Complicity

Corporate

Vicarious

Seriousness of offense

Felony

Infraction (also called Violation)

Misdemeanor

Inchoate offenses

Attempt

Conspiracy

Incitement

Solicitation

Offence against the person

Assassination

Assault

Battery

Bigamy

Criminal negligence

False imprisonment
Home invasion

Homicide

Kidnapping

Manslaughter (corporate)

Mayhem

Murder
o

Negligent homicide

Public indecency

corporate

Rape
Robbery

Sexual assault

Statutory rape
Vehicular homicide

Crimes against property

Arson

Blackmail

Bribery

Burglary

Embezzlement

Extortion
False pretenses

Larceny

Payola

Fraud

Pickpocketing

Possessing stolen property

Robbery

Smuggling

Tax evasion

Theft

Crimes against justice

Compounding

Malfeasance in office

Miscarriage of justice

Misprision

Obstruction

Perjury

Perverting the course of justice

Victimless crimes

Adultery

Apostasy

Blasphemy

Buggery

Providing Contraception information (Comstock

law)

Dueling
Fornication
Gambling
Adult incest

Interracial marriage

Lewd and lascivious behavior

Masturbation

Creation of Obscenity

Prostitution

Recreational drug use (including alcohol, when

prohibited)

Sale of sex toys

Sodomy

Suicide

Crimes against animals

Cruelty to animals

Wildlife smuggling

Bestiality

Defences to liability

Automatism

Defence of property
Diminished responsibility

Consent

Duress
Entrapment

Ignorantia juris non excusat

Infancy

Insanity

Justification
Mistake (of law)

Necessity

Provocation

Self-defence

Other common-law areas

Contracts

Evidence

Property

Torts

Wills, trusts and estates

Portals

Criminal justice

Law

Chapter 18 Insurance fraud

From Wikipedia, the free encyclopedia

Criminal law
Elements

Actus reus

Mens rea

Causation

Concurrence

Scope of criminal liability

Complicity

Corporate

Vicarious

Seriousness of offense

Felony

Infraction (also called Violation)

Misdemeanor

Inchoate offenses

Attempt
Conspiracy

Incitement

Solicitation

Offence against the person

Assassination

Assault

Battery

Bigamy

Criminal negligence

False imprisonment
Home invasion

Homicide

Kidnapping

Manslaughter (corporate)

Mayhem

Murder
o

corporate

Negligent homicide

Public indecency

Rape

Robbery

Sexual assault

Statutory rape
Vehicular homicide

Crimes against property

Blackmail

Bribery

Burglary

Embezzlement

Extortion
False pretenses

Fraud

Larceny

Payola

Arson

Pickpocketing

Possessing stolen property

Robbery
Smuggling

Tax evasion

Theft

Crimes against justice

Compounding

Malfeasance in office

Miscarriage of justice

Misprision

Obstruction

Perjury

Perverting the course of justice

Victimless crimes

Adultery

Apostasy

Blasphemy

Buggery

Providing Contraception information (Comstock

law)

Dueling
Fornication
Gambling

Adult incest

Interracial marriage

Lewd and lascivious behavior

Masturbation

Creation of Obscenity

Prostitution

Recreational drug use (including alcohol, when

prohibited)

Sale of sex toys

Sodomy

Suicide

Crimes against animals

Cruelty to animals

Wildlife smuggling

Bestiality

Defences to liability

Automatism

Consent

Defence of property
Diminished responsibility

Duress
Entrapment

Ignorantia juris non excusat

Infancy

Insanity

Justification
Mistake (of law)

Necessity

Provocation

Self-defence

Other common-law areas

Contracts

Evidence

Property

Torts

Wills, trusts and estates

Portals

Criminal justice

Law

Insurance fraud is any act committed with the intent to obtain a fraudulent outcome from an
insurance process. This may occur when a claimant attempts to obtain some benefit or advantage
to which they are not otherwise entitled, or when an insurer knowingly denies some benefit that
is due. According to the United States Federal Bureau of Investigation the most common
schemes include: Premium Diversion, Fee Churning, Asset Diversion, and Workers
Compensation Fraud. The perpetrators in these schemes can be both insurance company
employees and claimants.[1] False insurance claims are insurance claims filed with the intent to
defraud an insurance provider.
Insurance fraud has existed since the beginning of insurance as a commercial enterprise.[2]
Fraudulent claims account for a significant portion of all claims received by insurers, and cost
billions of dollars annually. Types of insurance fraud are diverse, and occur in all areas of
insurance. Insurance crimes also range in severity, from slightly exaggerating claims to
deliberately causing accidents or damage. Fraudulent activities affect the lives of innocent
people, both directly through accidental or intentional injury or damage, and indirectly as these
crimes cause insurance premiums to be higher. Insurance fraud poses a significant problem, and
governments and other organizations make efforts to deter such activities.

Chapter 19 Contents

1 Causes

2 Losses due to insurance fraud

3 Hard vs. soft fraud

4 Types of insurance fraud

o

4.1 Life insurance

4.2 Health care insurance

4.3 Automobile insurance

4.3.1 Staged collisions

4.3.2 Exaggerated claims

4.4 Examples

4.5 Property insurance

4.6 Council compensation claims

5 Detecting insurance fraud

6 Legislation
o

6.1 United States

6.2 Canada

6.3 United Kingdom

7 See also

8 Further reading

9 Bibliography

10 References

11 External links

Chapter 20 Causes
The chief motive in all insurance crimes is financial profit.[2] Insurance contracts provide both
the insured and the insurer with opportunities for exploitation.
According to the Coalition Against Insurance Fraud, the causes vary, but are usually centered on
greed, and on holes in the protections against fraud.[3] Often, those who commit insurance fraud
view it as a low-risk, lucrative enterprise. For example, drug dealers who have entered insurance
fraud [4] think its safer and more profitable than working street corners. Compared to those for
other crimes, court sentences for insurance fraud can be lenient, reducing the risk of extended
punishment. Though insurers try to fight fraud, some will pay suspicious claims anyway; settling
such claims is often cheaper than legal action.
Another reason for fraud is over-insurance, when the amount insured is greater than the actual
value of the property insured.[2] This condition can be very difficult to avoid, especially since an
insurance provider might sometimes encourage it in order to obtain greater profits.[2] This allows
fraudsters to make profits by destroying their property because the payment they receive from

their insurers is of greater value than the property they destroy. The most common form of
insurance fraud is inflating the value of the loss.[citation needed]
Insurance companies are also susceptible to fraud because it's possible for fraudsters to file
claims for damages that never occurred.

Chapter 21 Losses due to insurance fraud

It is hard place an exact value on the money stolen through insurance fraud. Insurance fraud is
deliberately undetectable, unlike visible crimes such as robbery or murder. As such, the number
of cases of insurance fraud that are detected is much lower than the number of acts that are
actually committed.[2] The best that can be done is to provide an estimate for the losses that
insurers suffer due to insurance fraud. The Coalition Against Insurance Fraud estimates that in
2006 a total of about $80 billion was lost in the United States due to insurance fraud.[5] According
to estimates by the Insurance Information Institute, insurance fraud accounts for about 10 percent
of the property/casualty insurance industrys incurred losses and loss adjustment expenses.[6] The
National Health Care Anti-Fraud Association estimates that 3% of the health care industrys
expenditures in the United States are due to fraudulent activities, amounting to a cost of about
$51 billion.[7] Other estimates attribute as much as 10% of the total healthcare spending in the
United States to fraudabout $115 billion annually.[8] Another study of all types of fraud
committed in the United States insurance institutions (property-and-casualty, business liability,
healthcare, social security, etc.)put the true cost at 33% to 38% of the total cash flow through the
system. This study resulted in the book title "The Trillion Dollar Insurance Crook" by J.E. Smith.
In the United Kingdom, the Insurance Fraud Bureau estimates that the loss due to insurance
fraud in the United Kingdom is about 1.5 billion ($3.08 billion), causing a 5% increase in
insurance premiums.[9] The Insurance Bureau of Canada estimates that personal injury fraud in
Canada costs about C$500 million annually.[10] Indiaforensic Center of Studies estimates that
Insurance frauds in India costs about $6.25 billion annually.[11]

Chapter 22 Hard vs. soft fraud

Insurance fraud can be classified as either hard fraud or soft fraud.[12]
Hard fraud occurs when someone deliberately plans or invents a loss, such as a collision, auto
theft, or fire that is covered by their insurance policy in order to receive payment for damages.
Criminal rings are sometimes involved in hard fraud schemes that can steal millions of dollars.[13]
Soft fraud, which is far more common than hard fraud, is sometimes also referred to as
opportunistic fraud.[12] This type of fraud consists of policyholders exaggerating otherwiselegitimate claims. For example, when involved in an automotive collision an insured person
might claim more damage than actually occurred. Soft fraud can also occur when, while
obtaining a new health insurance policy, an individual misreports previous or existing conditions
in order to obtain a lower premium on his or her insurance policy.[12]

Chapter 23 Types of insurance fraud

Chapter 24 Life insurance

See also: Category:Murderers for insurance money
Life insurance fraud may involve faking death to claim life insurance. Fraudsters may sometimes
turn up a few years after disappearing, claiming a loss of memory.[14]
An example of life insurance fraud is the John Darwin disappearance case, which was an
investigation into the act of pseudocide committed by the British former teacher and prison
officer John Darwin, who turned up alive in December 2007, five years after he was thought to
have died in a canoeing accident. Darwin was reported as "missing" after failing to report to
work following a canoeing trip on March 21, 2002. He reappeared on December 1, 2007,
claiming to have no memory of the past five years.
Another example is former British Government minister John Stonehouse who went missing in
1974 from a beach in Miami. He was discovered living under an assumed name in Australia,
extradited to Britain and jailed for seven years for fraud, theft and forgery.

Chapter 25 Health care insurance

See also: Medicare fraud and Health care fraud
Health insurance fraud is described as an intentional act of deceiving, concealing, or
misrepresenting information that results in health care benefits being paid to an individual or
group.
Fraud can be committed either by an insured person or by a provider. Member fraud consists of
claims on behalf of ineligible members and/or dependents, alterations on enrollment forms,
concealing pre-existing conditions, failure to report other coverage, prescription drug fraud, and
failure to disclose claims that were a result of a work-related injury.
Provider fraud consists of claims submitted by bogus physicians, billing for services not
rendered, billing for higher level of services, diagnosis or treatments that are outside the scope of
practice, alterations on claims submissions, and providing services while medical licenses are
either suspended or revoked. Independent medical examinations debunk false insurance claims
and allow the insurance company or claimant to seek a non-partial medical view for injuryrelated cases.
According to the Coalition Against Insurance Fraud, health insurance fraud depletes taxpayerfunded programs like Medicare, and may victimize patients in the hands of certain doctors.[15]
Some scams involve double-billing by doctors who charge insurers for treatments that never
occurred, and surgeons who perform unnecessary surgery.[16]
According to Roger Feldman, Blue Cross Professor of Health Insurance at the University of
Minnesota, one of the main reasons that medical fraud is such a prevalent practice is that nearly
all of the parties involved find it favorable in some way. Many physicians see it as necessary to

provide quality care for their patients. Many patients, although disapproving of the idea of fraud,
are sometimes more willing to accept it when it affects their own medical care. Program
administrators are often lenient on the issue of insurance fraud, as they want to maximize the
services of their providers.[17]
The most common perpetrators of healthcare insurance fraud are health care providers. One
reason for this, according to David Hyman, a Professor at the University of Maryland School of
Law, is that the historically-prevailing attitude in the medical profession is one of fidelity to
patients.[18] This incentive can lead to fraudulent practices such as billing insurers for treatments
that are not covered by the patients insurance policy. To do this, physicians often bill for a
different service, which is covered by the policy, rather than that which they rendered.[19]
Another motivation for insurance fraud is a desire for financial gain. Public healthcare programs
such as Medicare and Medicaid are especially conducive to fraudulent activities, as they are
often run on a fee-for-service structure.[20] Physicians use several fraudulent techniques to
achieve this end. These can include up-coding or upgrading, which involve billing for more
expensive treatments than those actually provided; providing, and subsequently billing for,
treatments that are not medically necessary; scheduling extra visits for patients; referring patients
to other physicians when no further treatment is actually necessary; "phantom billing," or billing
for services not rendered; and ganging, or billing for services to family members or other
individuals who are accompanying the patient but who did not personally receive any services.[20]
Perhaps the greatest total dollar amount of fraud is committed by the health insurance companies
themselves. There are numerous studies and articles detailing examples of insurance companies
intentionally not paying claims and deleting them from their systems,[21] denying and cancelling
coverage, and the blatant underpayment to hospitals and physicians beneath what are normal fees
for care they provide.[22] Although difficult to obtain the information, this fraud by insurance
companies can be estimated by comparing revenues from premium payments and expenditures
on health claims.
In response to the increased amount of health care fraud in the United States, Congress, through
the Health Insurance Portability and Accountability Act of 1996 (HIPAA), has specifically
established health care fraud as a federal criminal offense with punishment of up to ten years of
prison in addition to significant financial penalties.

Chapter 26 Automobile insurance

Fraud rings or groups may fake traffic deaths or stage collisions to make false insurance or
exaggerated claims and collect insurance money. The ring may involve insurance claims
adjusters and other people who create phony police reports to process claims.[23]
The Insurance Fraud Bureau in the UK estimated there have already been more than 20,000
staged collisions and false insurance claims across the UK from 1999 to 2006. One tactic
fraudsters use is to drive to a busy junction or roundabout and brake sharply causing a motorist
to drive into the back of them. They claim the other motorist was at fault because they were
driving too fast or too close behind them, and make a false and inflated claim to the motorist's

insurer for whiplash and damage which can give the fraudsters up to 30,000.[24] In the Insurance
Fraud Bureau's first year or operation, the usage of data mining initiatives exposed insurance
fraud networks and led to 74 arrests and a five-to-one return on investment.[25]
The Insurance Research Council estimated that in 1996, 21 to 36 percent of auto-insurance
claims contained elements of suspected fraud.[26] There is a wide variety of schemes used to
defraud automobile insurance providers. These ploys can differ greatly in complexity and
severity. Richard A. Derrig, vice president of research for the Insurance Fraud Bureau of
Massachusetts, lists several ways that auto-insurance fraud can occur,[27] such as:
Chapter 27 Staged collisions
In staged collision fraud, fraudsters use a motor vehicle to stage an accident with the innocent
party. Typically, the fraudsters' vehicle carries four or five passengers. Its driver makes an
unexpected manoeuvre, forcing an innocent party to collide with the fraudster's vehicle. Each of
the fraudsters then files claims for injuries sustained in the vehicle. A recruited doctor
diagnoses whiplash or other soft-tissue injuries which are hard to dispute later.
Other examples include jumping in front of cars as done in Russia. The driving conditions and
roads are dangerous with many people trying to scam drivers by jumping in front of expensivelooking cars or crashing into them. Hit and runs are very common and insurance companies
notoriously specialize in denying claims. Two-way insurance coverage is very expensive and
almost completely unavailable for vehicles over ten years oldthe drivers can only obtain basic
liability. Because Russian courts do not like using verbal claims, most people have dashboard
cameras installed to warn would-be perpetrators or provide evidence for/against claims.[28]
Chapter 28 Exaggerated claims
A real accident may occur, but the dishonest owner may take the opportunity to incorporate a
whole range of previous minor damage to the vehicle into the garage bill associated with the real
accident. Personal injuries may also be exaggerated, particularly whiplash.[29]

Chapter 29 Examples
Examples of soft auto-insurance fraud can include filing more than one claim for a single injury,
filing claims for injuries not related to an automobile accident, misreporting wage losses due to
injuries, or reporting higher costs for car repairs than those that were actually paid. Hard autoinsurance fraud can include activities such as staging automobile collisions, filing claims when
the claimant was not actually involved in the accident, submitting claims for medical treatments
that were not received, or inventing injuries.[30] Hard fraud can also occur when claimants falsely
report their vehicle as stolen. Soft fraud accounts for the majority of fraudulent auto-insurance
claims.[26]
Another example is that a person may illegally register their car to a location that would net them
cheaper insurance rates than where they actually live, sometimes called "rate evasion". For
example, some drivers in Brooklyn drive with Pennsylvania license plates because registering

their car in a rural part of Pennsylvania will cost a lot less than registering it in Brooklyn.
Another form of automobile insurance fraud, known as "fronting," involves registering someone
other than the real primary driver of a car as the primary driver of the car. For example, parents
might list themselves as the primary driver of their children's vehicles to avoid young driver
premiums.
"Crash for cash" scams may involve random unaware strangers, set to appear as the perpetrators
of the orchestrated crashes.[31] Such techniques are the classic rear-end shunt (the driver in front
suddenly slams on the brakes, possibly with brake lights disabled), the decoy rear-end shunt
(when following one car, another one pulls in front of it, causing it to brake sharply, then the first
car drives off) or the helpful wave shunt (the driver is waved into a line of queuing traffic by the
scammer who promptly crashes, then denies waving).[32]
Organized crime rings can also be involved in auto-insurance fraud, sometimes carrying out
schemes that are very complex. An example of one such ploy is given by Ken Dornstein, author
of Accidentally, on Purpose: The Making of a Personal Injury Underworld in America. In this
scheme, known as a swoop-and-squat, one or more drivers in swoop cars force an
unsuspecting driver into position behind a squat car. This squat car, which is usually filled with
several passengers, then slows abruptly, forcing the driver of the chosen car to collide with the
squat car. The passengers in the squat car then file a claim with the other drivers insurance
company. This claim often includes bills for medical treatments that were not necessary or not
received.[33]
An incident that took place on Golden State Freeway June 17, 1992, brought public attention to
the existence of organized crime rings that stage auto accidents for insurance fraud. These
schemes generally consist of three different levels. At the top, there are the professionals
doctors or lawyers who diagnose false injuries and/or file fraudulent claims and these earn the
bulk of the profits from the fraud. Next are the "capper (insurance fraud)s" or "runners", the
middlemen who obtain the cars to crash, farm out the claims to the professionals at the top, and
recruit participants. These participants at the bottom-rung of the scheme are desperate people
(poor immigrants or others in need of quick cash) who are paid around $1000 USD to place their
bodies in the paths of cars and trucks, playing a kind of Russian roulette with their lives and
those of unsuspecting motorists around them. According to investigators, cappers usually hire
within their own ethnic groups. What makes busting these staged-accident crime rings difficult is
how quickly they move into jurisdictions with lesser enforcement, after a crackdown in a
particular region. As a result, in the US several levels of police and the insurance industry have
cooperated in forming task forces and sharing databases to track claim histories.[34][35]
In the United Kingdom, there is an increasing incidence of false whiplash claims to car insurance
companies from motorists involved in minor car accidents (for instance; a shunt). Because the
mechanism of injury is not fully understood, A&E doctors have to rely on a patient's external
symptoms (which are easy to fake). Resultingly, "no win no fee" personal injury solicitors
exploit this "loophole" for easy compensation money (often a 2500 payout). Ultimately this has
resulted in increased motor insurance premiums, which has had the knock-on effect of pricing
younger drivers off the road.

Chapter 30 Property insurance

Possible motivations for this can include obtaining payment that is worth more than the value of
the property destroyed, or to destroy and subsequently receive payment for goods that could not
otherwise be sold. According to Alfred Manes, the majority of property insurance crimes involve
arson.[36] One reason for this is that any evidence that a fire was started by arson is often
destroyed by the fire itself. According to the United States Fire Administration, in the United
States there were approximately 31,000 fires caused by arson in 2006, resulting in losses of $755
million.[37] For example, the Moulin Rouge Hotel in Las Vegas was struck by arson twice within
six years.[38]

Chapter 31 Council compensation claims

The fraud involving claims from the councils' insurers suppose staging damages blamable on the
local authorities (mostly falls and trips on council owned land) or inflating the value of existing
damages.[39]

Chapter 32 Detecting insurance fraud

The detection of insurance fraud generally occurs in two steps. The first step is to identify
suspicious claims that have a higher possibility of being fraudulent. This can be done by
computerized statistical analysis or by referrals from claims adjusters or insurance agents.
Additionally, the public can provide tips to insurance companies, law enforcement and other
organizations regarding suspected, observed, or admitted insurance fraud perpetrated by other
individuals. Regardless of the source, the next step is to refer these claims to investigators for
further analysis.
Due to the sheer number of claims submitted each day, it would be far too expensive for
insurance companies to have employees check each claim for symptoms of fraud.[40] Instead,
many companies use computers and statistical analysis to identify suspicious claims for further
investigation.[41] There are two main types of statistical analysis tools used: supervised and
unsupervised.[40] In both cases, suspicious claims are identified by comparing data about the
claim to expected values. The main difference between the two methods is how the expected
values are derived.[40]
In a supervised method, expected values are obtained by analyzing records of both fraudulent
and non-fraudulent claims.[40] According to Richard J. Bolton and David B. Hand, both of
Imperial College in London, this method has some drawbacks as it requires absolute certainty
that those claims analyzed are actually either fraudulent or non-fraudulent, and because it can
only be used to detect types of fraud that have been committed and identified before.[40]
Unsupervised methods of statistical detection, on the other hand, involve detecting claims that
are abnormal.[40] Both claims adjusters and computers can also be trained to identify red flags,
or symptoms that in the past have often been associated with fraudulent claims.[42] Statistical
detection does not prove that claims are fraudulent; it merely identifies suspicious claims that
need to be investigated further.[40]

Fraudulent claims can be one of two types. They can be otherwise legitimate claims that are
exaggerated or built up, or they can be false claims in which the damages claimed never
actually occurred. Once a built up claim is identified, insurance companies usually try to
negotiate the claim down to the appropriate amount.[43] Suspicious claims can also be submitted
to special investigative units, or SIUs, for further investigation. These units generally consist
of experienced claims adjusters with special training in investigating fraudulent claims.[44] These
investigators look for certain symptoms associated with fraudulent claims, or otherwise look for
evidence of falsification of some kind. This evidence can then be used to deny payment of the
claims or to prosecute fraudsters if the violation is serious enough.[45]
Determining fraud committed by the health insurance companies can sometimes be found by
comparing revenues from premiums paid against the expenditure by the health insurance
companies on claims.
As an example, in 2006 the Harris County Medical Society, in Texas, had a health insurance rate
increase of 22 percent for consumer-driven health plan from Blue Cross and Blue Shield of
Texas. This was despite the fact that during the previous year Blue Cross had paid out only 9
percent of the collected premium dollars for claims.[22]

Chapter 33 Legislation
National and local governments, especially in the last half of the twentieth century, have
recognized insurance fraud as a serious crime, and have made efforts to punish and prevent this
practice. Some major developments are listed below:

Chapter 34 United States

Insurance Fraud is specifically classified as a crime in all states, though a minority of

states only criminalize certain types (e.g. Oregon only outlaws Worker Compensation and
Property Claim fraud).[12]

The Coalition Against Insurance Fraud was founded in 1993 to help fight insurance fraud.
This organization collects information on insurance fraud, and is the only anti-fraud
alliance speaking for consumers, insurance companies, government agencies and others.
Through its unique work, the Coalition empowers consumers to fight back, helps fraud
fighters better detect this crime and deters more people from committing fraud. The
Coalition supports this mission with a large and continually expanding armory of
practical tools: Information, research & data, services and insight as a leading voice of
the anti-fraud community.

Approximately one third of these investigations result in criminal conviction, one third
result in denial of the claim, and one third result in payment of the claim.[48]

19 states require mandatory insurer fraud plans. This requires companies to form
programs to combat fraud and in some cases to develop investigation units to detect
fraud.[12]

41 states have fraud bureaus. These are law enforcement agencies where investigators
review fraud reports and begin the prosecution process.[12]

Section 1347 of Title 18 of the United States Code states that whoever attempts or carries
out a scheme or artifice to defraud a health care benefit program will be fined under
this title or imprisoned not more than 10 years, or both. If this scheme results in bodily
injury, the violator may be imprisoned up to 20 years, and if the scheme results in death
the violator may be imprisoned for life.[46]

Besides making laws more severe, Legislation has also come up with a list for management that
should be implemented so that companies are better suited to combat the possibility of being
scammed. That list includes:

Understanding that fraud does exist and that there is a high possibility for it happening.

Being fully aware of the dangers and severity of the problem.

Understanding the importance of the hiring process and how important it is to hire honest
individuals.

Learn to deal with the economic side of business. That means putting procedures and
policies in place to catch and deal with individuals trying to commit fraud. [47]

Chapter 35 Canada

The Insurance Crime Prevention Bureau was founded in 1973 to help fight insurance
fraud. This organization collects information on insurance fraud, and also carries out
investigations. Approximately one third of these investigations result in criminal
conviction, one third result in denial of the claim, and one third result in payment of the
claim.[48]

British Columbias Traffic Safety Statutes Amendment Act of 1997 states that any person
who submits a motor vehicle insurance claim that contains false or misleading
information may on the first offence be fined C$25,000, imprisoned for two years, or
both. On the second offense, that person may be fined C$50,000, imprisoned for two
years, or both.[49]

Chapter 36 United Kingdom

A major portion of the Financial Services Act 1986 was intended to help prevent fraud.[50]

The Serious Fraud Office, set up under the Criminal Justice Act 1987, was established to
improve the investigation and prosecution of serious and complex fraud.[50]

The Fraud Act 2006 specifically defines fraud as a crime. This act defines fraud as being
committed when a person makes a false representation, fails to disclose to another

person information which he is under a legal duty to disclose, or abuses a position in

which he or she is expected to safeguard, or not to act against, the financial interests of
another person. This act also defines the penalties for fraud as imprisonment up to ten
years, a fine, or both.[51]

Chapter 37 See also

Federal Bureau of Investigation

Florida Division of Insurance Fraud

Horse murders

Split billing

Chapter 38 Further reading

The Invisible Bankers: Everything the Insurance Industry Never Wanted You to Know
(book)

Viaene S. & Dedene G. Insurance fraud: issues and challenges. Geneva Papers on Risk
and Insurance. 29 (2) : 313 -333, 2004 (article)

Chapter 39 Bibliography

Bolton, Richard J. and David J. Hand. "Statistical Fraud Detection: A Review." Statistical
Science. 17.3 (2002): 235-249.

Clarke, Michael. "The Control of Insurance Fraud, A Comparative View." The British
Journal of Criminology. 30.1 (1990): 1-23.

Coalition Against Insurance Fraud. Annual Report. Washington, DC: Coalition Against
Insurance Fraud, 2006.

Coalition Against Insurance Fraud. "Insurance Fraud Hall of Shame: Mother Almost
Blamed for Son's Arson." 31 12 2006. Coalition Against Insurance Fraud. 13 December
2007.[52]

Coalition Against Insurance Fraud. "Learn About Fraud." Coalition Against Insurance
Fraud. 1 December 2007.[53]

Derrig, Richard A. "Insurance Fraud." The Journal of Risk and Insurance. 69.3 (2002):
271-287.

Dornstein, Ken. Accidentally on Purpose: The Making of a Personal Injury Underworld

in America. New York: St. Martin's Press, 1996.

Feldman, Roger. "An Economic Explanation for Fraud and Abuse in Public Medical Care
Programs." The Journal of Legal Studies. 30.2 (2001): 569-577.

Ghezzi, Susan Guarino. "A Private Network of Social Control: Insurance Investigative
Units." Social Problems. 30.5 (1983): 521-531.

Hyman, David A. "Health Care Fraud and Abuse: Market Change, Social Norms, and the
Trust 'Reposed in the Workmen'." The Journal of Legal Studies. 30.2 (2001): 531-567.

Insurance Information Institute. "Fraud." Insurance Information Institute. 1 December

2007.[54]

Insurance Information Institute. "Insurance Fraud." Insurance Information Institute. 1

December 2007.[55]

Insurance Information Institute. "No-Fault Insurance Fraud in N.Y. State." Insurance

Information Institute. 1 December 2007.[56]

Legislative Assembly of British Columbia. "Traffic Safety Statutes Amendment Act."

1997.

Manes, Alfred. "Insurance Crimes." Journal of Criminal Law and Criminology 35.1
(1945): 34-42.

Ministry of Justice. "Fraud Act 2006." 11 August 2006. The UK Statute Law Database.
13 December 2007.[57]

National Health Care Anti-Fraud Association. "The Problem of Health Care Fraud."
National Health Care Anti-Fraud Association. 1 December 2007.[58]

Office of the Law Revision Counsel, U.S. House of Representatives. "United States
Code; Title 18, Section 1347." 2 January 2006.[59]

Pontell, Henry N., Paul D. Jesilow and Gilbert Geis. "Policing Physicians: Practitioner
Fraud and Abuse in a Government Medical Program." Social Problems. 30.1 (1982): 117125.

Staple, George. "Serious and Complex Fraud: A New Perspective." The Modern Law
Review. 56.2 (1993): 127-137.

Tennyson, Sharon and Pau Salsas-Forn. "Claims Auditing in Automobile Insurance:

Fraud Detection and Deterrence Objectives." The Journal of Risk and Insurance. 69.3
(2002): 289-308.

U.S. Fire Administration. "Arson Fire Statistics." 11 October 2007. U.S. Fire
Administration. 13 December 2007.[60]

United States of America v. Naseem Chaudhry. United States District Court, Northern
District of Illinois, Eastern Division. February 2005.

Viaene, Stijn, et al. "A Comparison of State-of-the-Art Classification Techniques for

Expert Automobile Insurance Claim Fraud Detection." The Journal of Risk and
Insurance. 69.3 (2002): 373-421.

Chapter 40 References
1.
"FBI Insurance Fraud". Fbi.gov. 2005-09-08. Retrieved 2014-02-07.
Manes, Alfred. "Insurance Crimes." p. 34.
"Why Fraud Persists". Coalition Against Insurance Fraud. Insurancefraud.org. April 4,
2012.
Kendall, Marisa. Southwest Florida gangs eschew street for Internet, [1] The News Press
- Fort Myers, Fla. January 17, 2012
Coalition Against Insurance Fraud. Annual Report.
Insurance Information Institute. "Insurance Fraud."
National Health Care Anti-Fraud Association. "The Problem of Health Care Fraud."
Hyman, David A. "Health Care Fraud and Abuse." p. 532.
Insurance Fraud Bureau. "Fighting Organized Insurance Fraud." p. 2.
Insurance Bureau of Canada. "Cost of Personal Injury Fraud."
"Indiaforensic Study on quantification of fraud losses to Indian Insurance Sector "
Insurance Information Institute. "Fraud."
Coalition Against Insurance Fraud. "Learn About Fraud."
Summers, Chris (17 November 2004). "Couple face 'fake drowning' trial". BBC.
Retrieved 17 November 2004.
Quiggle, James. [2] "Health Fraud" Scam Alerts. Coalition Against Insurance Fraud, 2011
U.S. Attorney's Office (2011-07-26). "Salisbury Cardiologist Convicted of Implanting
Unnecessary Cardiac Stents". FBI.
Feldman, Roger. "Economic Explanation." p. 569-570.
Hyman, David A. "Health Care Fraud and Abuse." p. 541.
Hyman, David A. "Health Care Fraud and Abuse." p. 547.
Pontell, Henry N., et al. "Policing Physicians." p. 118.
Fried, Joseph P. (2000-08-02). "Metro Business; New York State Fines Insurer
$500,000". The New York Times.
"hcfan.3cdn.net" (PDF). Retrieved 2012-02-03.
"San Diego Fraud Ring Cracked". Insurance Journal. 20 December 2002. Retrieved 24
April 2006.
Howard, Bob (16 December 2006). "Fraud body warns of crash scams". BBC. Retrieved
2 December 2007.

 Grant, Ian (9 August 2007). "Insurance Fraud Bureau's data-mining initiatives net
fraudsters". Computer Weekly. Retrieved 2 December 2007.
Tennyson, Sharon et al. "Claims Auditing" p. 289.
"Insurance Fraud" (PDF). Retrieved 8 August 2013.
Galperina, Marina (13 June 2012). "Why Russians Are Obsessed With Dash-Cams".
Jalopnik. Retrieved 19 November 2012.
Press Association (2012-12-11). "Government plans to cut whiplash injury claims |
Money | guardian.co.uk". Guardian. Retrieved 2013-06-08.
Derrig, Richard A. "Insurance Fraud." p. 274.
"BBC News - Car crash scams at record level". Bbc.co.uk. 2010-08-21. Retrieved 201008-21.
The One Show Team - September 15, 2008 3:50 PM (2008-09-15). "Crash for cash - a
scam for the unquestioning? - Consumer". Bbc.co.uk. Retrieved 2010-08-21.
Dornstein, Ken. Accidentally on Purpose. p. 3.
"motherjones.com". motherjones.com. 1992-06-17. Retrieved 2012-02-03.
Robertson, Grant; Perkins, Tara (2010-12-27). "How small-time auto insurance scams
have evolved into big business in Canada". The Globe and Mail (Toronto).
Manes, Alfred. "Insurance Crimes." p. 35.
U.S. Fire Administration. "Arson Fire Statistics."
[3][dead link]
"Housing and Council Tax Benefit fraud - Allerdale Borough Council". Allerdale.gov.uk.
2009-11-02. Retrieved 2010-08-21.
Bolton, Richard J. Statistical Fraud Detection. p. 236.
Derrig, Richard A. "Insurance Fraud." p. 277.
Viaene, Stijn, et al. "Insurance Claim Fraud Detection." p. 375.
Derrig, Richard A. "Insurance Fraud." p. 278.
Viaene, Stijn, et al. "Insurance Claim Fraud Detection." p. 374.
Ghezzi, Susan Guarino. " Private Network."
Office of the Law Revision Counsel, U.S. House of Representatives. "United States
Code."
Silverstone, Howard; Davia, Horward R. (April 13, 2005). Fraud 101: Techniques and
Strategies for Detection. Hoboken, New Jersey: John Wiley & Son, Inc. p. 6. ISBN 9780471721123.
Clarke, Michael. The Control of Insurance Fraud. p. 10.
Legislative Assembly of British Columbia. "Traffic Safety Statutes Amendment Act."
Staple, George. "Serious and Complex Fraud." p. 127.
Ministry of Justice. "Fraud Act 2006."
"Articles on insurance fraud". insurancefraud.org. 2006-12-31. Retrieved 2010-08-21.
"Learn about fraud". Insurancefraud.org. Retrieved 2010-08-21.
"Fraud". III. Retrieved 2010-08-21.
"Insurance Fraud". III. Retrieved 2010-08-21.
"Conozca los deducibles por huracanes y si aplica a su pliza de seguro de propietario
de vivienda". III. Retrieved 2010-08-21.
"Fraud Act 2006 (c. 35) - Statute Law Database". Statutelaw.gov.uk. 2007-01-15.
Retrieved 2010-08-21.
"Anti-Fraud Resource Center". nhcaa.org. Retrieved 2010-08-21.

 "U.S. Code". Uscode.house.gov. Retrieved 2010-08-21.

"USFA Arson Fire Statistics". Usfa.dhs.gov. 2010-01-05. Retrieved 2010-08-

1.
21.

Chapter 41 External links

What is Auto Insurance Fraud and How to Prevent it? Carsnaps.com (this link no longer
valid)

India losing $6.25 billion to Insurance Frauds

Insurance Information Institute. Insurance Information Institute.

Coalition Against Insurance Fraud. Coalition Against Insurance Fraud.

National Health Care Anti-Fraud Association

National Insurance Crime Bureau. National Insurance Crime Bureau.

Insurance Bureau of Canada

UK Insurance Fraud Bureau

Insurance Research Council

U.S. Fire Administration. United States Fire Administration.

2009 Florida report: Impacts of the Economy and Insurance Fraud

California: Department of Insurance; Fraud: What is Insurance Fraud?

UK Insurance Fraud Register

[show]

Insurance
[show]

Types of fraud
Categories:

Crimes

Fraud

Finance fraud

Insurance law

Property crimes

Insurance

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