Are All Cases Fraudulent That are Worked by a Insurance Investigator? #135

Is every case worked by an investigator because the insurance company believes the claim is fraudulent? Some people believe it is.  Even some investigators believe this to be true.  But the truth is that much of the work I do in the insurance investigation field doesn’t relate to fraud at all.

Much of Insurance Work is About Information Collecting

I will probably write about this topic again,  but for now I am going to address a conversation I had with an insurance investigator and the mentality that I want to warn you not to have as an investigator.

We are all Human

I understand we are all human.  But I believe that all investigators need to work files in a non-bias matter.  They need to work all assignments with an open mind.  Whether it be when conducting surveillance, investigating accidents, investigating home thefts, investigating vehicle thefts, slip and fall accidents, workers compensation claims, disability claims or any file worked.  Like many other occupations we need to be held to a certain standard, a higher standard.  And the higher standard I will be focusing on is investigating with no bias towards a file that is being worked.

Two Types of Investigators

I have had conversations with numerous investigators over the years regarding the files they were working.  Some investigators are very detached from the work.  Being detached doesn’t mean they don’t care about doing a good job on the assignment, they just don’t take things personally. They don’t care if someone is fraudulent or not. They don’t go into each investigation believing that the person is guilty of being fraudulent just because an insurance company has asked to investigate or find out more information about a claim.  This type of investigator understands that insurance companies don’t always hire private investigators because they think a claim is fraudulent.

Investigations
Investigator Report Writing

Then there is the other type of investigator. This investigator believes that every claim being work is because an insurance claim is potentially fraudulent.  Why else would an insurance company investigate a claim?  At least that is what they believe.

So I know someone in the  insurance investigation industry that believes every claim (or almost every claim) is fraudulent.  Whether it be someone they are conducting surveillance on or any other claim they are investigating, they first believe  there is some fraud involved unless proven different.  Almost every conversation with this investigator regarding the files they were working implied there was something fraudulent.

When this investigator talked about a surveillance the investigator would describe every movement as if that movement made the claim fraudulent.  So I asked this investigator how many cases they worked where they believed fraud was involved. This investigator told me they believed most of the files they worked were fraudulent.  After all, that is why the insurance company has investigators working file (this is what they believed)

I think I about lost my crap when I heard that.  Why did it bother me so much?  First because this investigator was wrong.  Secondly because that mentality creates bias in the investigation.  This misled bias starts off the investigation with the investigator believing that a claim is not legit.  And this type of mentality has the potential  to influence how claimants are treated and how a report is written.  It’s that bias I was talking about that is not good for the claim, the claimant and the client.

Here’s the thing.  When it comes to insurance companies assigning a surveillance to an investigator they are trying determine whether a claim is legit or not.  Typically there are red flags that trigger an insurance company to even assign a surveillance.  And just because the person the investigator is conducting surveillance on is active and doing things doesn’t mean they are doing anything wrong.   The investigator is not a doctor. An investigator doesn’t know a claimant’s/insured’s medical history.  An investigator doesn’t know what the person is allowed to do physically or not allowed to do.  All the investigator is responsible for is documenting as much as they can of the individual they are watching.  After documenting the activity the investigator submits the documentation to the insurance company.

When it comes to investigating claims there isn’t always some obvious thing in the claim that makes the insurance company think something fraudulent is going on. Sometimes insurance companies just need more detailed information about the claim because it is complex or there is just too much information to gather that they need help.  Sometimes the information they have about a claim has been misunderstood and is cleared up after being interviewed by an investigator.  Investigators collect information and provide it to a client so they can make an informed decision about a claim.  It’s that simple.

Our goal as insurance investigators is to be an unbiased party collecting information so that when we conduct a surveillance the report is written in a observant manner only.  It is not to contain you opinions (in most cases) and it is not meant to have what you observed to be slanted to make the actions of a claimant or insured appear worse then they really area.  When we interview witness, claimants and insured parties we are interviewing and information collecting not interrogating.

Just do the work and keep your feelings and bias out of the work product.  End Rant.

Andrew

 

2 comments

  1. As a private investigator, and previously as a government investigator, I have worked thousands of cases and supervised dozens of investigators and attorneys.

    In all of that I have never started an investigation with the mindset that “this SOB is guilty and I am going to get him!”

    In fact, I do not care one way or the other whether evidence of guilt is found. Besides, evidence of innocence is just as valuable as that of guilt.

    What I do care about is doing the best job that I can do as a professional, using all the resources available to me, and giving each case 100% of my ability … to obtains facts and evidence … and if my own abilities and skills are insufficient to the task, then finding the knowledge and/or personnel to supplement my own.

    Past cases have included fraud allegations ranging from 100s of millions of dollars, to low-rent time clock cheats, to criminal activity by government officials at the highest levels.

    I never come to conclusion on a case until all the work is done and all the evidence is analyzed and evaluated. Even then, I cannot count the number of cases in which I felt the evidence was pointing in one direction in the middle of report writing – only to reach a different, final conclusion by the end of the process.

    If at the beginning one decides on guilt, innocence, evidence, then everything they do subsequently will in their mind lead back to the pre-determined conclusion. That is a certainty.

    And that is NOT what we are paid for.

    In my contracts it states clearly that I/my agency will conduct the investigation on behalf of the client in such manner as I deem in my sole and exclusive discretion to be appropriate for the purpose stated. If a client pushes me to come to a pre-determined conclusion I will cancel the contract and direct him or her to go look for a vigilante who is unconcerned with facts, evidence, objectivity, or truth.

    Gilbert Jimenez
    Insight Investigation Services, LLC
    Chicago, Illinois