Potential signs of insurance fraud

Watch for these signs of potential fraud at your business.

The problem of insurance fraud goes beyond the potential financial impact to an insurance company. When a fraudulent incident is staged, it costs time and money for everyone involved. 

If a slip and fall accident is staged at a business, for example, the management team will spend time responding, working with their insurance company on the claim, and possibly having to close or make changes to their operations, costing indirect financial losses. And, too often, insurance fraud cases can cause dangerous situations for innocent people.

According to the Coalition Against Insurance Fraud, insurance fraud costs at least $80 billion every year, affecting consumers, business owners and insurance companies. Businesses are at risk every day for insurance fraud, including slips and falls and workers compensation claims. No business is immune to fraud. In fact, small businesses (those with less than 100 employees) suffer the same median fraud loss as organizations with 10,000 or more employees.

Wha's insurance fraud? 

Insurance fraud happens when someone intentionally lies to get a financial benefit or advantage from an insurance policy. On the other hand, fraud can also occur if someone knowingly denies a benefit that is due and to which a person is entitled.

As an insurance claim is processed there are a few phases during which a person could knowingly misrepresent information to the insurance company in order to obtain a benefit. For example, during the initial investigation phase of a car accident, a person could lie about the type of accident, the circumstances, the time, the location, the type and extent of damages sustained, and who was involved. 

As a business owner, it's important to look out for signs of insurance fraud. Here are some signs you might watch for when an incident occurs.  And it's important to remember that often more than one type of fraud takes place in a single claim. In the slip and fall example, there might be signs that someone is lying about the extent of medical benefit needed and the amount of earnings they lost from alleged missed work.  

Typical signs of potential casualty insurance fraud

Watch for a person making a claim who:

  • Appears to be "claim smart" - unusually familiar with insurance terms and procedures, medical, or vehicle repair terminology.
  • Eagerly accepts blame for an accident or is overly pushy or demanding of a quick or reduced settlement.
  • Provides a P.O. box or hotel address, does not have a permanent address or alleges to be on vacation.
  • Wants to conduct all transactions in person and avoids using phone, mail or email.
  • Threatens to seek an attorney or a physician if the claim is not quickly settled.

Typical signs of a potentially fraudulent car accident

  • The accident occurred shortly after one or more of the vehicles were purchased or registered, or after the addition of comprehensive and collision coverage to the policy.
  • Either no police report or an over-the-counter report for an accident with multiple injuries and/or extensive physical damage.
  • The claimant has a history of accidents within a short period of time.
  • Index returns show multiple claim activity matching to name, Social Security number, address, telephone or other related information.
  • The claimant has no record of prior insurance for recently damaged vehicle.
  • There's no lienholder for the recent purchase of expensive, late model automobile - paid cash.
  • The attorney's letter of representation or lien filing is dated the day of the accident or soon after.

Typical signs of potential auto physical damage fraud

  • It's a serious accident with extensive physical damage, but only a minor injury is diagnosed with subjective findings that require little or no medical treatment.
  • In spite of expensive physical damages claimed, the claimant's vehicle remains drivable.
  • Often, there are no towing charges for removing vehicle from the scene of the accident.
  • The claimant prefers to send in photos of the damages, and none of the photos show license plates of the vehicle.
  • The vehicle will not be repaired locally - vehicle will either be shipped or driven out of state.
  • The claimant's vehicle was struck by a rental vehicle which had recently been rented.
  • All vehicles involved in the accident are taken to the same body repair shop.
  • The claimant's vehicles are not readily available for appraisal or inspection.
  • The reported accident occurred on private property near the residence address of parties involved.

Typical signs of potential medical fraud, or claim inflation

  • Three or more people alleging the same type of injury.
  • All injuries are subjectively diagnosed, such as headaches, muscle spasms, traumas and others.
  • Medical claims are extensive, but collision is minor with little physical damage to vehicles.
  • Medical bills submitted to document the claim are photocopies of originals.
  • All of the claimants show treatment rendered at the same facility, by the same physician.
  • All of the claimants show the same diagnosis and treatment plan.
  • Medical bills indicate routine treatment being provided, including dates for Sundays and holidays.
  • Summary medical bills are submitted without dates and descriptions of office visits and treatments.
  • The claimant vehicle is an older model with minimum limits coverage.
  • Insured is adamant that he was not at fault, indicating the possibility that the insured may have been targeted by the claimants.
  • Claimants retain legal representation immediately after the accident is reported. 
  • Minor accident produces major medical costs, lost wages and expensive demands for pain and suffering.

Typical signs of potential lost earnings fraud

  • The person's employment information shows an unknown business, often with a P.O. box address or a street address in a residential zone.
  • The business telephone number is connected to an answering machine or answering service.
  • The lost earnings statement is handwritten or typed on blank paper, not business letterhead.
  • The claimant is self-employed or started employment shortly before the accident occurred.
  • One or more elements of the claim are questionable - for example, the length of absence, rate or pay or income declared is incompatible with the claimant's residence or social lifestyle.
  • Efforts to verify lost wage statement with the employer raise doubts about the employer's legitimacy or about the actual employment of the claimant.

Typical signs of potential slip and fall and potential food products liability fraud

  • An overly enthusiastic witness is present at the scene of the accident.
  • No evidence is found to support existence of a foreign object or contaminated substance that caused the alleged injury.
  • If the person making the claim:
    • Fails to report immediate notice of the incident, which delays investigation efforts
    • Refuses to provide a face-to-face recorded interview or statement
    • Will not sign a medical authorization release
    • Is willing to accept a cash settlement for amount of medical bills alone

Remember, it's important to take steps to address potential fraud before an incident is reported. Keep your business safe by implementing safety programs and keeping them up to date. If your business notices signs of insurance fraud, it's best to report the fraud as soon as possible to your insurance agent or company.



State Auto Insurance makes no representations or guarantee as to the correctness or sufficiency of any information contained herein, nor guarantees results based upon use of this information. State Auto does not warrant that reliance upon this document will prevent accident and losses or satisfy federal, state and local codes, ordinances and regulations. The reader assumes entire risk as to use of this information.

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