It’s a common misconception, but workers’ compensation insurance companies do not determine workers’ comp fraud. Business owners, employers or workers’ compensation judges also don’t determine fraud. In reality, fraud is determined by criminal juries.
Law enforcement investigators and prosecutors use the referrals from insurance carrier Special Investigations Units to determine if charges should be filed. Prosecutors will then need to present clear and convincing evidence to a jury. The accused, being afforded the right to legal representation, will defend the case to the best of their ability. Fraud, you see, is a criminal concept. However, it may originate in a civil arena. It is this civil arena where insurance claims exist.
What is the role of the employer, the Claims Examiner, and the Special Investigations Unit in cases reaching criminal juries for that determination as to whether “fraud” occurred? The short answer is that we work in partnership to uncover evidence to support that “fraud” appears to have occurred.
So what elements is law enforcement looking for when it comes to potentially fraudulent activity? While each case is unique, and the means to uncover the evidence of the schemes varies by case, ICW Group has developed a simple acronym to describe those necessary elements, “B.I.T.E.”
B – Did they BENEFIT?
I – Was the act INTENTIONAL?
T – Did they TELL a lie?
E – Is there EVIDENCE?
Did they BENEFIT? – A key element of insurance fraud is the attempt by the claimant to be paid for something they were not eligible to be paid for. Prosecutors will commonly ask what the suspected loss is if a claimant is believed to have committed fraud.
Was the act INTENTIONAL? – Did the claimant knowingly misrepresent themselves? A mistake in recollection or accidental omission may not have been intentional.
Did they TELL a lie? – This is the one we all know to be a necessary element of fraud. It’s a lie to secure a benefit you would not otherwise be eligible for.
Is there EVIDENCE? – This is the key. You do not have fraud without clear and convincing evidence and proof. This is the difference between suspicion and a solid referral to law enforcement.
Making the case for fraud
ICW Group’s Special Investigations Unit’s primary responsibility is assisting our Claims Department in the accurate adjudication of claims and therefore defending our customers from insurance fraud. More specifically, when fraud red flags are present, and a false claim is suspect, our investigators will seek to identify available evidence that either resolves or affirms those red flag concerns.
The evidence identified will then be used by the Claims Examiner to appropriately manage the underlying claim, the civil element. ICW Group’s Special Investigations Unit will then consider that same evidence to determine if the essential elements of “B.I.T.E.” are present, and if they are, report their findings to law enforcement so that the criminal element may then be considered by that prosecutor. If a criminal charge is ultimately filed, a jury will be asked to make the final determination.
What are juries looking for?
What are juries looking for when determining if the crime of fraud has occurred? This can vary from case to case, but it is reasonable to believe that the more compelling the case, the more equipped a jury is to make a determination. EVIDENCE that is weak will be argued as such. A jury will see a lack of clarity about the lie they attempted to TELL, or whether it was truly INTENTIONAL.
A claimant need not be successful in attempting insurance fraud for insurance fraud to have occurred. Costs are naturally incurred in investigating the red flags which may be attributable to the worker’s attempt. Commonly, however, juries may be more appalled if the claimant can be shown to directly benefit to some extent.
Knowing the elements which constitute a well-documented referral to law enforcement for workers’ compensation fraud and how ICW Group’s Special Investigations Unit is partnering with you to present these cases to law enforcement provides that extra peace of mind the next time a claim is filed. Continue to provide your Claims Examiner with a full rundown of concerns you may have about a claim, especially focusing on areas of evidence of which you may be aware. Don’t hesitate to reach out to ICW Group’s Special Investigations Unit if you need additional assistance.
Contact ICW Group’s Special Investigations Unit:
Fraud Hotline: 855-ICW-FRAUD (429-3728)