Red Flags

Each insurer has its individual threshold that provides the reason to hire an investigator. Inconsistencies, red flags and missing pieces of the puzzle are recorded and outlined on each suspicious file. When there are unanswered questions, red flags arise. Making reference to these factors when assigning a file to an investigator means the file has been assigned with careful consideration and in the least invasive way possible.

Adjusters recognize red flags based on the inconsistencies in a particular file. These red flags enable the adjuster to instruct the investigator to direct attention to problem areas for background checks or surveillance. The resulting investigation becomes an invaluable tool to determining accuracy of information and activities because it is done without the claimant’s awareness, meaning the evidence has been collected in a natural state.

To effectively and efficiently complete an investigation, it is important for the adjuster to ensure the information provided to the investigator has been confirmed as accurate. Such accuracy can save thousands of dollars when it comes to surveillance. Preliminary background searches can confirm starting information, can assist in the direction of surveillance and lead to other areas of investigation that will assist in successfully settling a claim.

It is a sign of the times that growing numbers of adjusters carry large case loads. So assigning files to an investigator can appear to be tedious work for an adjuster. It is important to realize there are many options to identifying the focus of investigative requirements. Moreover, the adjuster must be aware an assignment can be completed much more successfully if the investigator is provided with as much information as possible about the claim. A postal code when reversed may lead to a different address than provided; small details may provide great insight. Even if the file is inundated with paperwork, the investigator, for his part, should review it and become very familiar with the claim.

A recent trend of a trail of little white lies that hide the claimant’s address and personal information can lead to uneventful investigations. This trend has come and gone over the years, and has great influence where surveillance is concerned. Preliminary background inquiries should be utilized as the starting point. When the insurance adjuster has determined the red flags and purpose of the investigation, the resulting background inquiries can identify and confirm the claimant’s address, employment and activities in order to conduct surveillance in its natural form.

The Internet has provided new leads that were not available to the gumshoes of yore. There is a wealth of public information that can be obtained through research and background. Public documents are still available, as long as they are accessed through proper channels. The flow of online documents has provided investigators with great avenues to search, unlike the old city directories at libraries. A preliminary background investigation can provide leads for surveillance, social media including photos, activities and relationships. This ensures a higher level of successful investigation in a cost effective manner.  
Insurance claims consist of an abundance of forms and invoices from service providers that can be overwhelming at times. Background investigation has become a valuable and cost effective tool that can provide great insight into the legitimacy of clinics, employers and transportation carriers. In recent months, a number of new medical specialties, including allergy testing, have provided invoices to insurers. Such specialty clinics are emerging and evolving every month. With each development, we must find a way to verify, validate or reject new invoice types.

Due diligence has come to the fore in the matter of evaluating new invoice types. Relationships between representatives, clinics and transportation providers may link to auto repair shops, tow truck drivers and companies connected to a fraudulent ring. A simple due diligence investigation on such services can provide adjusters with the evidence and insight needed to validate or dismiss the invoices at hand.

With the ever-growing number of injury claims, despite fewer accidents being reported in Ontario, investigations have become necessary to deter and fight fraud in the insurance industry. Through identifying the red flags and carrying out effective investigations, the industry can send a clear message to those who breach insurance contracts and make false claims. 

The Canadian Association of Special Investigation Units (CASIU) is a low-profile association whose members come from the claims side of the P&C industry.