ICC The World of Technology In Forensics Investigation
Forensic Science pertains to law, primarily the interface of the law with other disciplines such as insurance, accident reconstruction, medical accident reconstruction , fraud investigation, policy interpretation analysis, bad faith, insurance claims, and computer insurance analysis.
Forensic Insurance is conducted in a context involving the interface of Insurance and the law . Forensic assessments in the insurance industry require more extensive data collected than most insurance companies and lawyers obtain in assessing their client's case. e.g. forensic experts require a thorough review and analysis of ALL records and symptom validity testing.
Forensic Insurance Policy Experts Our experts trained in policy construction and interpretation analysis. Policy experts give the theory behind the making of the insurance policy and what the policy was intended to do in terms of profit/ loses for the insurance company or self -insurer.
Forensic Insurance Claims Experts Our experts trained in liability claims. Claim experts require more extensive data in evaluating claims and reconstructs the accident and injuries to determine the validity of the loss. Forensic Insurance claims experts are trained in accident reconstruction, injury reconstruction, medical review, case management , medical and interface their findings with the law .
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COMMERCIAL PROPERTY LOSS - FIRE, THEFT
There is no doubt that fraud is costing companies, businesses, and individuals to pay, continually, higher insurance premiums.
Insurance provides many benefits to our society. However, these benefits ARE NOT COST-FREE. Premiums, for the insured, are charged in order to collect the necessary money to pay the losses of the insured.
The fraud and abuse occurs from moral and morale hazards.
To some extent, the existence of insurance coverage encourages losses.
Even though insurers have an economic incentive to encourage loss control, insurance sometimes provides an economic incentive for insured's to have losses.
Moral Hazard
Moral hazard is a condition that exists when a person may intentionally try to cause a loss or may exaggerate a loss that has occurred. Nobody knows for sure how many car or building fires are started intentionally by people who would rather have the insurance money than the car or building.
More common are exaggerated or inflated claims. An insured may claim that four times were lost rather than the actual three or that the items were worth more than their actual value. In liability situations, third-party claimants often exaggerate their personal injuries and property damage, and sympathetic physicians, lawyers, auto body shops, and contractors may support these exaggerations and drive up the cost of claims.
Morale Hazard
Morale hazard is a condition that exists when a person is less careful because of the existence of insurance.
Morale hazard does not involved an intent to cause or exaggerate a loss. Instead, the insured becomes careless about potential losses because insurance is available. Leaving the keys in an unlocked car or allowing fire hazards to remain uncorrected are examples of morale hazard.
Moral hazard results in additional losses that drive up the costs of insurance because of injuries and damage that could have been prevented.
The following are some of the indicators ICC considers in their investigation of potential insurance claims:
GENERAL
Recent increase in coverage
Loss occurred shortly after inception date of policy or
shortly before expiration of
policy period
Insured verifies existence and extent of coverage
shortly before loss
Undisclosed duplicate coverage
Insured willing to settle for substantially less than the
purported value of the claim
in order to speed
claims settlement process or to avoid documentation of claim
Over-familiarity
with claims process
Extensive history of similar claims, particularly claims not
disclosed by insured
Unwillingness by insured to respond to questions concerning
the loss or injury or to
provide
documentation of same.
Commercial Property Loss - fire, theft
Any indication that the business is having financial
difficulties or has immediate need for funds
Deteriorated or outmoded facilities, business is in bad
location or deteriorating neighborhood
Machinery, production equipment or inventory is obsolete or
unmarketable
Property is over-insured
Unusual presence of combustible material on the premises
Unusual handling of combustible materials normally present on
the premises
Presence of multiple fires, accelerants
Evidence that valuable property was recently removed from the
premises or relocated to a safer place within the premises
Any departure from long-standing routine (failure to activate
alarm system; shut-down of sprinkler system; discharge of security guard)
No evidence of unlawful entry or evidence of
unlawful entry appears to have been manufactured
Real property is heavily mortgaged
Business personal property secures multiple and substantial
debts
Recent history of late payments or default on loans
Principals in business have history of business failures
Recent expansion of business facilities which caused insured
to incur substantial debt; other over-extension
Radically differing accounts of accident or manner in which
loss occurred, including inconsistent reports from the same person
Overlapping ownership of related businesses with inventory
moving readily between businesses without adequate documentation
Poor economic climate for particular business
Damaged property discarded or not readily available for
inspection.
Insured experiencing marital difficulties, including separation,
divorce, substantial child support obligation or recent increase in child support
obligation.
History of transiency when ownership of property lost is
inconsistent with transient lifestyle
History of gambling or alcohol or drug abuse
Insured has spotty work history or extended period of
unemployment
Poor economic climate for insured's profession or trade
Property lost or destroyed was being advertised for sale
Loss limited to high ticket or scheduled items
Insured's lifestyle is inconsistent with income
Value of property lost is inconsistent with insured's income
Too many receipts to support claim ~e.g. insured produces
receipt for socks purchased 6 months prior to loss)
Too few receipts, especially for recently purchased, high
ticket items still under warranty
Receipts are suspicious in nature (no store identification on
receipt, consecutively numbered receipts, large number of undated receipts)
Recent movement of valuable or sentimental property to place
of safety
Unexplained absence of typical household items or
non-combustible items at fire scene
Unexplained absence of family pet at time fire or illegal
entry occurred
No evidence of unlawful entry or evidence of unlawful entry
which appears to have been manufactured
Pattern of past claims or losses
Property heavily mortgaged or insured otherwise financially
overextended
insured's' movements unaccounted for at time of loss
Unexplained departure from habits
Radically differing accounts of accident or manner in which
Loss occurred, especially inconsistent reports from the same person
Damaged property discarded or not readily available for
inspection.
Insured/claimant has extensive history of claims/accidents
Descriptions of occurrence vary widely or are virtually
identical suggesting rehearsal
Legal representation sought shortly after injury occurred
No treatment sought for injuries until a substantial period
of time elapsed after the accident or until legal representation is obtained
Course of treatment is questionable (no apparent relationship
between injuries claimed and treatment provided; minor injuries result in major medical
costs; medical bills are out of balance with treatment obtained)
Documentation of treatment is suspect (photocopies of bills
supplied; no record of dates of treatment; no itemization of treatment provided)
Majority of complaints are subjective and incapable of
corroboration
Claim for pain and suffering is not consistent with severity
of injuries
Long-standing relationship between attorney and treating
physician
In products cases, injury-producing product has been lost or
destroyed
SPECIAL CONSIDERATIONS APPLICABLE TO AUTOMOBILE ACCIDENTS
Damage to vehicle is inconsistent with injuries claimed
Absence of police report where logic dictates that a report
should have been made
Existence of multiple claimants as a result of same accident
whose injuries vary widely in degree
Multiple, unrelated occupants of same vehicle
Relationship among occupants creates possibility of collusion
Multiple claimants obtain representation from same attorney
Multiple claimants obtain treatment from same physician and
follow similar course of treatment
SPECIAL CONSIDERATIONS APPLICABLE TO WORKERS' COMPENSATION CLAIMS
Unwitnessed Monday morning accident
Claimant can seldom be reached by phone during the day
Claimant repeatedly misses or reschedules doctor's
appointments
Nature and extent of alleged injuries are inconsistent with
how the accident occurred and/or doctor's diagnosis
The claimant's co-worker has a prior history of workers'
compensation or liability claims
The claimant is self-employed or has a job that would allow
the claimant to work for cash while collecting temporary disability
The claimant's employer is experiencing financial or labor
difficulties
Claimant's job performance is poor and/or claimant has taken
significant sick time for unexplained illness
ICC only investigates the facts thoroughly and presents the findings in a detailed report.
ICC services are NATIONWIDE!
ICC consultants have professional insurance backgrounds in fraud and have saved many major insurance companies millions of dollars in investigating insurance fraud.
ICC has also, helped insurance companies as "Third Party Interveners" in the payment of claims promptly, without undue delay, by being able to rule out suspicious or vague insurance claims that are presented to the company.
ICC investigates UNFAIR CLAIMS PRACTICES vs. INSURANCE FRAUD INVESTIGATIONS. In most cases, insurance companies are not guilty of Unfair Claim Practice and most questionable claims can be "Cleared Up" with a thorough investigation.
ICC is impartial and fair in investigating Unfair Claim practice questions and writes a thorough report involving the following:
1) Misrepresenting pertinent facts of insurance policy provisions relating to
coverage at issue.
2) Failing to acknowledge and act reasonably and promptly upon communications with
respect to claims arising out of insurance policies.
3) Failing to adopt and implement reasonable standards for the
prompt investigation of claims arising under insurance policies.
4) Refusing to pay claims without conducting a reasonable investigation based upon
all available information.
5) Failing to confirm or deny coverage of claims within a reasonable time after
proof of loss statement has been completed.
6) Not attempting in good faith to effectuate fair and equitable settlements of
claims in which liability has become reasonably clear.
7) Compelling insured to institute litigation to recover amounts due under an
insurance policy by offering substantially less than the amount ultimately recovered in
actions brought by such insureds.
8) Attempting to settle a claim for less than the amount to which a reasonable man
would have believed he was entitled by reference to written or printed advertising
material accompanying or made part of an application.
9) Attempting to settle claims on the basis of an application which was altered
without notice to, or knowledge or consent of the insured.
10) Making claims payments to insured or beneficiaries not accompanied by a statement
setting forth the coverage under which the payments are being made;
11) Making known to insureds. or claimants a policy of appealing from arbitration awards
in favor of insureds or claimants for the purpose of compelling them to accept settlements
or compromises less than the amount awarded in arbitration.
12) Delaying the investigation or payment of claims by requiring an insured, claimant, or
the physician of either to submit a preliminary claim report and then requiring the
subsequent submission of formal proof of loss forms, both of which submissions contain
substantially the same information.
13) Failing to promptly settle claims where liability has become reasonably clear under
one portion of the insurance policy coverage in order to influence settlements under other
portions of the insurance policy coverage.
14) Failing to promptly provide a reasonable explanation of the basis in the insurance
policy in relation to the facts or applicable law for denial of a claim or for the offer
of a compromise settlement.
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