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Insurance fraud - Wikipedia
Insurance fraud is any act committed to defraud an insurance process. It occurs when a claimant attempts to obtain some benefit or advantage they are not entitled to, or when an insurer knowingly denies some benefit that case study 4 the columbia accident due. According to the United States Federal Bureau of Investigationthe most common schemes include premium diversion, fee churning, asset diversion, and workers compensation fraud. Perpetrators in the schemes can be insurance company employees or claimants.
Insurance fraud has existed since the beginning of insurance as a commercial enterprise. Types of insurance fraud are diverse and occur in all areas of insurance.
Insurance crimes also range in severity, from slightly exaggerating claims to deliberately causing accidents or damage. Fraudulent activities affect the lives of innocent people, both directly through accidental or intentional injury or damage, and indirectly by the crimes leading to higher insurance premiums.
Insurance fraud poses a significant problem, and governments and other organizations try to deter such activity. An epigram by the Roman poet Martial provides a clear evidence the phenomenon of insurance fraud was already known in the Roman Empire during the First Century AD: [3]. The "chief motive in all insurance crimes is financial profit". According to the Coalition Against Insurance Fraudthe causes vary, but are usually centered on greed, and on holes in the protections against fraud.
For example, drug dealers who have entered insurance fraud [5] think it's safer and more profitable than working street corners. Compared to those for other crimes, court sentences for insurance fraud can be lenient, reducing the risk of extended punishment.
Though insurers fight fraud, some pay suspicious claims anyway, as settling such claims is often cheaper than legal action. Another basis for fraud is over-insurance, case study 4 the columbia accident, in which someone insures property for more than its real value. The most common forms of insurance fraud are re-framing a non-insured damage to make it an event covered by insurance, and inflating the value of the loss.
It is hard to place an exact value on the money stolen through insurance fraud. Insurance fraud is deliberately undetectable, unlike visible crimes such as robbery or murder. As such, the number of cases of insurance fraud that are detected is much lower than the number of acts that are actually committed.
This study resulted in the book title "The Trillion Dollar Case study 4 the columbia accident Crook" by J. In the United Kingdomthe Insurance Fraud Bureau estimates that the loss due to insurance fraud in the United Kingdom is about £ case study 4 the columbia accident. Insurance fraud can be classified as either hard fraud or soft fraud. Hard fraud occurs when someone deliberately plans or invents a loss, such as a collision, auto theft, or fire that is covered by their insurance policy [15] in order to claim payment for damages.
Criminal rings are sometimes involved in hard fraud schemes that can steal millions of dollars. Soft fraudwhich is far more common than hard fraud, is sometimes also referred to as opportunistic fraud.
For example, when involved in an automotive collision an insured person might claim more damage than actually occurred. Soft fraud can also occur when, while obtaining a new health insurance policyan individual misreports previous or existing conditions to obtain a lower premium on the insurance policy. The majority of life insurance fraud occurs at the application stage, involving applicants misrepresenting their health, case study 4 the columbia accident, their income, case study 4 the columbia accident, and other personal information in order to get a cheaper premium.
As more and more insurance amendments can be performed online or over the telephone, identity theft has become an enabling crime that can lead to the amendment of life insurance terms to benefit a fraudster; for example, by adding a second stolen identity as a new beneficiary. Life insurance fraud may involve faking death to claim life insurance.
Fraudsters may sometimes turn up a few years after disappearing, claiming a loss of memory. An example of life insurance fraud occurred in the case of John Darwina former teacher and prison officer who turned up alive in Decemberfive years after he was thought to have died in a canoeing accident, claiming to have no memory of the period after his disappearance. Similarly, former British Government minister John Stonehouse went missing in from a beach in Miami but was discovered living under an assumed name in Australia.
He was subsequently extradited to Britain and imprisoned for seven years on charges of fraud, theft, and forgery. Health insurance fraud is described as an intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group.
Fraud can be committed either by an insured person or by a provider. Provider fraud consists of claims submitted by bogus physicians, billing for services not rendered, billing for higher level of services, diagnosis or treatments that are outside the scope of practice, alterations on claims submissions, and providing services while medical licenses are either suspended or revoked.
Independent medical examinations debunk false insurance claims and allow the insurance company or claimant to seek a non-partial medical view for injury-related cases.
According to the Coalition Against Insurance Fraudhealth insurance fraud depletes taxpayer-funded programs like Medicare, and may victimize patients in the hands of certain doctors. According to Roger Feldman, Blue Cross Professor of Health Insurance at the University of Minnesotaone of the main reasons that medical fraud is such a prevalent practice is that nearly all of the parties involved find it favorable in some way.
Many physicians see it as necessary to provide quality care for their patients. Many patients, although disapproving of the idea of fraud, are sometimes more willing to accept it when it affects their own medical care. Program administrators are often lenient on the issue of insurance fraud, as they want to maximize the services of their providers. The most common perpetrators of healthcare insurance fraud are health care providers. One reason for this, according to David Hyman, a Professor at the University of Maryland School of Lawis that the historically-prevailing case study 4 the columbia accident in the medical profession is one of "fidelity to patients".
To do this, physicians bill for a different service that the policy covers, rather than the service they rendered. Another motivation for insurance fraud is a desire for financial gain. Public healthcare programs such as Medicare and Medicaid are especially conducive to fraudulent activities, as they are often run on a fee-for-service structure.
These can include "up-coding" or "upgrading", which involve billing for more expensive treatments than those actually provided; providing, case study 4 the columbia accident, and subsequently billing for, treatments that are not medically necessary; scheduling extra visits for patients; referring patients to other physicians when no further treatment is actually necessary; "phantom billing", billing for services not rendered; and "ganging", billing for services to family members or case study 4 the columbia accident individuals who are accompanying the patient but who did not personally receive any services.
Perhaps the greatest total dollar amount of fraud is committed by the health insurance companies themselves. There are numerous studies and articles case study 4 the columbia accident examples of insurance companies intentionally not paying claims and deleting them from their systems, [24] denying and cancelling coverage, case study 4 the columbia accident, and the blatant underpayment to hospitals and physicians beneath what are normal fees for care they provide.
In response to the increased amount of health care fraud in the United States, Congressthrough the Health Insurance Portability and Accountability Act of HIPAAhas specifically established health care fraud as a federal criminal offense with punishment of up to ten years of prison in addition to significant financial penalties.
Fraud rings or groups may fake traffic deaths or stage collisions to make false insurance or exaggerated claims and collect insurance money. The ring may involve insurance claims adjusters and other people who create phony police reports to process claims.
The Insurance Fraud Bureau in the UK estimated there were more than 20, staged collisions and false insurance claims across the UK from to One tactic fraudsters use is to drive to a busy junction or roundabout and brake sharply causing a motorist to drive into the back of them. They claim the other motorist was at fault because they were driving too fast or too close behind them, and make a false and inflated claim to the motorist's insurer for whiplash and damage, which can pay the fraudsters up to £30, The Insurance Research Council estimated that in21 to 36 percent of auto-insurance claims contained elements of suspected fraud.
These ploys can differ greatly in complexity and severity. Richard A. Derrigvice president of research for the Insurance Fraud Bureau of Massachusettslists several ways that auto-insurance fraud can occur, [30] such as:.
In staged collision fraud, fraudsters use a motor vehicle to stage an accident with the innocent party. Typically, the fraudsters' vehicle carries four or five passengers. Its driver makes an unexpected manoeuvre, forcing an innocent party to collide with the fraudster's vehicle. Each of the fraudsters then files claims for injuries sustained in the vehicle. A "recruited" doctor diagnoses whiplash or other soft-tissue injuries that are hard to dispute later.
Other examples include jumping in front of cars case study 4 the columbia accident done in Russia. The driving conditions and roads are dangerous with many people trying to scam drivers by jumping in front of expensive-looking cars or crashing into them. Hit and runs are very common and insurance companies notoriously specialize in denying claims.
Two-way insurance coverage is very expensive and almost completely unavailable for vehicles over ten years old—the drivers can only obtain basic liability. A real accident may occur, but the dishonest owner may take the opportunity to incorporate a whole range of previous minor damage to the vehicle into the garage bill associated with the real accident.
Personal injuries may also be exaggerated, particularly whiplash. Examples of soft auto-insurance fraud include filing more than one claim for a single injury, filing claims for injuries not related to an automobile accidentmisreporting wage losses due to injuries, and reporting higher costs for car repairs than those that were actually paid.
Hard auto-insurance fraud can include activities such as staging automobile collisions, filing claims when the claimant was not actually involved in the accident, submitting claims for medical treatments that were not received, case study 4 the columbia accident, or inventing injuries.
Soft fraud accounts for the majority of fraudulent auto-insurance claims, case study 4 the columbia accident. Another example is that a person may illegally register their car to a location that would net them cheaper insurance rates than where they actually live, sometimes called rate evasion.
For example, some drivers in Brooklyn have Pennsylvania license platescase study 4 the columbia accident, because insurance rates for a car registered to an address in rural Pennsylvania are much less than they are in Brooklyn, case study 4 the columbia accident. Another form of automobile insurance fraudknown as "fronting", involves registering someone other than the real primary driver of a car as the primary driver of the car, case study 4 the columbia accident.
For example, parents might list themselves as the primary driver of their children's vehicles to avoid young driver premiums. Organized crime rings can also be involved in auto-insurance fraud, sometimes carrying out schemes that are very complex. An example of one such ploy is given by Ken Dornsteinauthor of Accidentally, on Purpose: The Making of a Personal Injury Underworld in America. In this scheme, known as a "swoop-and-squat", one or more drivers in "swoop" cars force an unsuspecting driver into position behind a "squat" car.
This squat car, which is usually filled with several passengers, then slows abruptly, forcing the driver of the chosen car to case study 4 the columbia accident with the squat car. The passengers in the squat car then file a claim with the other driver's insurance company. This claim often includes bills for medical treatments that were not necessary or not received.
An incident that took place on Golden State Freeway June 17,brought public attention to the existence of organized crime rings that stage auto accidents for insurance fraud. These schemes generally consist of three different levels.
Next are the " cappers " or "runners", the middlemen who obtain the cars to crash, farm out the claims to the professionals at the top, and recruit participants. According to investigators, cappers usually hire within their own ethnic groups, case study 4 the columbia accident. What makes busting these staged-accident crime rings difficult is how quickly they move into jurisdictions with lesser enforcement, after a crackdown in a particular region. As a result, in the US several levels case study 4 the columbia accident police and the insurance industry have cooperated in forming task forces and sharing databases to track claim histories.
In the United Kingdomcase study 4 the columbia accident, there is an increasing incidence of false whiplash claims to car insurance companies from motorists involved in minor car accidents for instance; a shunt. Resultingly, "no win no fee" personal injury solicitors exploit this " loophole " for easy compensation money often a £ payout.
Ultimately this has resulted in increased motor insurance premiums, which has had the knock-on effect of pricing younger drivers off the road.
Possible motivations for this can include obtaining payment that is worth more than the value of the property destroyed, or to destroy and subsequently receive payment for goods that could not otherwise be sold. According to Alfred Manes, the majority of property insurance crimes involve arson. Unemployment insurance fraud can occur when someone who is not unemployed or who steals the identity of another individual obtains unemployment benefits to which he or she is not entitled.
Duringthere was a significant spike of unemployment fraud in the United States.
Accident Case Study: Cross-Country Crisis
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