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According to the Coalition Against Insurance Fraud:

 

Conservatively, fraud steals $80 billion a year across all lines of insurance. (Coalition Against Insurance Fraud estimate). Fraud comprises about 10 percent of property-casualty insurance losses and loss adjustment expenses each year; and Property-casualty fraud thus equals about $32 billion each year. (Insurance Information Institute, March 2016.

Fraud Costs for Insurers:

Fraud accounts for 5-10 percent of claims costs for U.S. and Canadian insurers. Nearly one-third of insurers (32 percent) say fraud was as high as 20 percent of claims costs;

57 percent of insurers predict an increase in personal-property fraud by policyholders. Around 58 percent say the same for personal auto insurance, and 69 percent expect a rise in workers-compensation scams;

61 percent predict an increase in auto-insurance fraud by organized rings, and 55 percent predict an increase workers-compensation scamming;

About 35 percent say fraud costs their companies 5-10 percent of claim volume. More than 30 percent say fraud losses cost 10-20 percent of claim volume; Detecting fraud before claims are paid, and upgrading analytics, were mentioned most often as the insurers’ main fraud-fighting priorities.

 

Automobile Bodily Injury Claims

Staged-crash rings fleece auto insurers out of billions of dollars a year by billing for unneeded treatment of phantom injuries. Usually these are bogus soft-tissue injuries such as sore backs or whiplash, which are difficult to medically identify and dispute.

Hotspot states for Insurance Fraudsters Pennsylvania, New Jersey, Delaware and New York Claimed losses for medical expenses, lost wages and other expenses related to injuries from auto crashes in the New York City area have risen 70 percent over the past decade. This surpasses the 49-percent increase in medical-care inflation over the same period; Nearly one in four claims (23 percent) involved the appearance of claim abuse — fraud, material misrepresenting of facts, or buildup;
Claims from the Philadelphia metro area were more than four times as likely to involve apparent abuse (35 percent v. 8 percent for the rest of the state); 
More than half of apparently abusive claims (52 percent) stemmed from accidents in Philadelphia. (Insurance Research Council, November 2011).

Public Attitudes Regarding Insurance Fraud:

A relatively large number of consumers remain at risk of committing this crime. They believe it’s acceptable to increase insurance claims to mak

Man thinking

e up for deductibles. Even so, those numbers have declined in recent years. 

  • 24 percent say it’s acceptable to pad an insurance claim to make up for the deductible — 33 percent said it’s acceptable in 2002;
  • 18 percent believe it’s acceptable to pad a claim to make up for premiums paid in the past;
  • Younger males were much more likely to condone claim padding. And 23 percent of 18-34 year-old males say it’s alright to increase claims to make up for earlier premiums. This compares with 5 percent of older males and 8 percent of females of the same age;
  • 86 percent of Americans think “insurance fraud leads to higher rates for everyone;” and
  • 10 percent think “insurance fraud doesn’t hurt anyone.” (Insurance Research Council, March 2013)

 

Workers Compensation:

More than one in 10 small-business owners are concerned an employee will fake an injury or illness to steal workers-compensation benefits;

Nearly one in four owners also installed surveillance cameras to monitor employees on the job;
One in five owners feel unsure how to identify workers-compensation scams; 
More than half agree these are fraud flags: Employee has a history of claims (58 percent); no witnesses to the incident (52 percent); employee didn’t report the injury or illness in a timely manner (52
percent); and the injury coincides with a change in employment status (51 percent). (Employers Holdings, July 2015).

Misclassification:
Some businesses illegally try to avoid paying full state-required workers compensation premiums by misclassifying employees as independent contractors. Such schemes are spreading. The number of employees and size of payroll are two important factors that
workers-compensation insurers use to gauge a firm’s premiums. Typically such workers are paid off the books to hide the evidence. Another scheme involves misclassifying employees in high-risk jobs as holding lower-risk jobs. A dishonest roofing firm, for example, might tell its insurer that its high-risk roofers are lower-risk sales staff or clerks. Workers also are denied state-required workers compensation benefits. And misclassification avoids taxes, wages and other expenses. Overall, this crime gives employers an unfair advantage over competitors. The Obama Administration expanded the definition of “employee” under the Fair Labor Standards Act in July 2015 to crack down on employers that misclassify workers as independent contractors.
10-20 percent of businesses misclassify at least one worker as an independent contractor. (Economic Policy Institute, June 2015). 25 states have signed Memorandums of Understanding with the U.S. Department of Labor to combat misclassification. (U.S. Department of Labor, August 2015).


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TRI STATE DETECTIVE AGENCY

Two Bala Plaza

Suite 300

Bala Cynwyd, PA 19004

267 - 733 6166

Serving

Pennsylvania- New Jersey - New York

 

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