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Red Flags in Your Personal Injury Claim that Can Trigger a Fraud Investigation

Anthony J. Caiazzo April 4, 2022

Fraud costs insurance carriers millions of dollars every year. As a result, insurance carriers look for potential fraud during both the application and claims processes. At the very least. a fraud investigation gives the insurance company an excuse to delay paying your claim. At worst, you may be facing civil or criminal penalties. In this article, Delaware Valley personal injury claimant’s lawyer, Anthony Caiazzo, discusses red flags that may trigger a fraud investigation upon the filing of a claim.

Claimant Provides Contradictory Information

When a claim is filed, the insurance carrier may run a variety of reports that provide a window into the claimant’s personal life and claims history. Any information that appears in a report that contradicts information the claimant previously provided to the carrier is a red flag. For example, if a claimant has, for years, reported that he lives at a certain address, but a report run by the carrier reveals that the claimant never lived at that address, this will result in an investigation. Even if the investigation ultimately reveals that the information on the report was incorrect, the carrier will take this opportunity to investigate any other potentially false information the claimant may have provided.

Written and Verbal Statements Contradict One Another

Most carriers will try to obtain both a written and a verbal statement from each claimant. Any contradictory details within these statements or “facts” that generally do not make sense will become a red flag for fraud. As an example, assume that in the driver’s statement form, the claimant writes that she was leaving work when she was involved in the accident, but in her verbal statement to the insurance adjuster she says she was coming home from the store. It could be that the claimant stopped at the store on her way home from work and was then involved in the accident, but an investigation will likely be conducted to confirm the facts based on her contradictory statements.

Lack of Police Report or Contradictory Information in Report

If you are involved in an accident that results in serious injuries and/or significant property damage, then the insurance company expects that the police will be called to the scene. If there is no police report or if information on the police report does not comport with the statements provided to the carrier, this will trigger a fraud investigation. Without a police report, the carrier does not have an independent person’s account of the facts nor can it confirm that a loss in fact occurred. Even when a police report exists, there may be errors within the report that contradict information provided by the claimants. The carrier will investigate to seek clarification from the claimant, the officer, and witnesses to determine the accuracy of the facts.

Delays in Treatment

Delays in treatment and treatment for seemingly unrelated injuries may also result in a fraud investigation. Although there are times when gaps in treatment are easily explained, generally someone injured in an accident will follow a designated course of treatment. When that person begins treatment weeks or even months after the accident, questions arise as to whether that treatment is in fact for injuries related to the accident. Similarly, treatment for injuries that were not initially disclosed to the claims adjuster as a result of the accident may trigger an investigation. Although injuries or symptoms may surface some time after an accident, normally a claimant will provide a detailed list of complaints either to a medical provider or directly to the insurance adjuster soon after the accident. New complaints unrelated to those initially provided may be investigated as unrelated to the accident.

Contact Us

Insurance adjusters are skeptical, if not by nature then certainly by training. If they see a red flag, or if their gut says something is not quite right, they will investigate. This is true even of wholly legitimate claims that may, for one reason or another, set off alarm bells. Personal injury claimant’s lawyer Anthony Caiazzo understands how insurance companies work and knows how to deal with adjusters. If you are concerned that your claim may be under investigation, or if you have other questions or concerns about your case, contact us. You can reach us by phone or email.