Fraud Awareness, Identification and Action Training

Transcription

1 Fraud Awareness, Identification and Action Training Marshall Katz Please turn cell phones to silent, vibrate or off. Why is this Course important to You as a member of the insurance community and as a Consumer? Fighting fraud can keep rates down Fighting fraud can keep your agency s loss ratios down Lower loss ratios = profitability Profitability = boss may be able to stay in business Help your customers get paid by encouraging them to tell the truth Aiding and abetting fraud is a felony. And its required under the MA Auto Insurance Plan (MAIP) Rules 2

2 Aiding and Abetting Who is required to report insurance fraud suspicions? Generally, insurance company personnel who have reason to believe that a Massachusetts insurance transaction may be fraudulent, or who have knowledge that a fraudulent insurance transaction is about to take place, or has taken place in Massachusetts, are required by law to report the suspected fraud to the Insurance Fraud Bureau of Massachusetts within 30 days. Insurers and insurance personnel licensed under G.L.c. 175 and exempt from the licensing requirments of G.L.c 175 and others engaged in the business of insurance under the IFB enabling statute must comply with the mandated reporting provision. Massachusetts St. 1990, c. 338 as amended by Section 99 of 398 Mass Acts 1991, and Section 13 of 427 Mass Acts 1996 and Section 5 of 279 Mass Acts MAIP Massachusetts Automobile Insurance Plan Current ARPs (Assigned Risk Producers) and their employees are required under Rule 31 to receive training on claim reporting and fraud recognition New employees trained within 6 months of hire that touch an auto policy in any way New Hire Checklist 4

3 The Fraud Problem The Property Casualty Insurer Association of America found that: Every year approximately $30 billion is lost industry wide to insurance fraud. It is estimated that $12.3 billion is related to automobile insurance. Fraudulent insurance claims whether related to automobile, medical or workers compensation take more than 30 cents out of every dollar your customers pay for insurance premiums 5 The Fraud Problem The Coalition Against Insurance Fraud shows that: Nearly one of ten Americans would commit insurance fraud if they knew they could get away with it. Nearly three of ten Americans wouldn't report insurance scams committed by someone they know. Nearly one of four Americans says it s ok to defraud insurers. Two of five people are not very likely or not likely at all to report someone who ripped off an insurer. 6

4 INTRODUCTION The purpose of this seminar is to train the Massachusetts Insurance Community on fraud recognition and claim reporting. It has been developed by the Claims Advisory Producer Training Subcommittee whose members include representatives from Insurance Company Underwriting, Claims, and Training Departments and Special Investigative Units, Commonwealth Automobile Reinsurers, the Massachusetts Association of Insurance Agents, and the MA Insurance Fraud Bureau. The information presented provides an overview of the impact of fraud on the Massachusetts insurance market and indicates how producers and their staff can assist in the fight against fraud. Agents should follow the procedures and requirements given to you by the insurance companies you represent. 7 Course Objectives Provide information that will increase agent awareness of policy fraud. Provide information regarding the legal consequences of policy fraud and the effect on your clients claim payout. Review the questions on the application that if answered falsely, incompletely, or in a misleading or deceptive way can give rise to an insurer s right to take action. 8

5 Course Objectives Discuss the rights that an insurer may have under provisions of the Mass. Auto Policy when false information is provided. Discuss what you can do up front to recognize and stop premium fraud so that your clients claims can be processed without delays. Provide a listing of Red Flags that should alert you to the suspicion of potential fraud on both premium and claims transactions. 9 Student Objectives At the conclusion of the session you will be able to: Recognize major indicators of fraud within the application process. Identify fraud indicators which are present within the loss reporting process. Understand your role in the effort to identify and combat fraud. Develop an approach for reporting application and loss reporting fraud to the issuing company. These four objectives will be covered in the skill practice workshops. 10

6 Fraud Defined What is Fraud? Webster's Dictionary defines Fraud as: An intentional perversion of the truth in order to induce another to part with something of value or to surrender a legal right; an act of deceiving or misrepresenting. 11 Fraud Defined The key element of fraud is a false and material misrepresentation made by one who either knows its falsity or is ignorant of its truth. In Massachusetts, misrepresentation also includes unintentional acts such as failing to notify the company of any changes that would increase the risk of loss. Fraud in Insurance might be defined as the abuse of the insurance mechanism for financial gain. 12

7 Premium Fraud Types of Fraud Falsifying information on an insurance application which results in a lower rate Failing to inform or omitting on the policy renewal or Renewal Questionnaire (statement of fact) of changes that would increase the premium such as a new address or operator. 13 Claims Fraud Types of Fraud Inflating a claim to cover a deductible Having a car stolen or burned Exaggerating an injury and over treating to qualify for a higher settlement Staged accidents Jump-ins of passengers claiming to be in accident Paper cars 14

8 Provider Fraud Types of Fraud Doctors over treat or falsify treatment records Lawyers work with Doctors to inflate medical bills Body shops cause additional damage to inflate repair costs or total vehicle Fraud can be perpetrated by the insured or someone working on their behalf or by another party against your insured. 15 First Party Fraud First party fraud is fraud committed with the involvement of the insured and or someone subject to first party benefits. The insured is aware and participating in the fraudulent activity. Investigating this type of fraud is made difficult by the issues presented when an insured is involved in fraud. A Reservations of Rights needs to be considered. If the claim does not resolve, litigation is complicated by the involvement of the insured. 16

9 First Party Fraud EXAMPLES The Hit and Run occurs when an insured uses a damaged vehicle and claims to be the victim of a hit and run. The police are often called to verify the damage. Paper Accidents are just that they occur only on paper. An owner fabricates an accident report to cover existing damage, or to collect insurance money for non-existent damage. Application Fraud occurs when vehicle owners use a friend s or relative s address or misrepresent how far they drive to work, all for the sake of obtaining a lower auto insurance premium. 17 Third Party Fraud Third party fraud is fraud committed by someone against another person or business, without an insurer/insured relationship. The fraudster is generally an outsider. The insured may be unaware and not consciously participating in the fraudulent activity. This fraud is very difficult to identify and fully investigate because one party (the insured) is not involved in the fraud. To this individual a legitimate accident occurred and their statements will be truthful. 18

10 Third Party Fraud EXAMPLES The Swoop and Squat The vehicle in front of you stops abruptly, and you find yourself the responsible party in a rear-end collision. Only this is no accident the other driver planned the collision, and expects to submit vehicle damage and personal injury claims against your insurance company. The Drive Down When you try to merge into traffic or out of a parking space, the fraudster helpfully waves you ahead, then intentionally drives into you. Then, of course, the driver denies waving you on. Often there will be a witness nearby who claims to have seen the whole thing and corroborates the fraudster s version. The Side Swipe In a dual left-turn at a busy intersection, the driver in the inside lane drifts into the outer lane, intentionally forcing a collision. 19 Anti-Runner Law This new law, passed January 3, 2005, now makes it a felony to act as a runner for the purpose of defrauding an insured or an insurance carrier. Runners are individuals who are paid to stage accidents and to direct clients to health care providers. *Runners may approach agency personnel and offer them money or gifts to provide the names of injured insureds. 20

11 CAR Rules of Operation Rule 31 Assigned Risk Producer Requirements B. Ongoing Exclusive Representative Producer Requirements: 15. The ARP must notify the MAIP & ARC of any suspected fraud surrounding a loss; 16. The ARP must cooperate with the ARC and MAIP personnel during all audits and investigations; 21 CAR Rules of Operation Rule 30 Assigned Risk Company Requirements B. 4 c. Verify that information contained in the application for insurance is accurate as to classification, garaging, discounts, credits, vehicle use, vehicle description and, to the extent verifiable, other rating factors. B. 4 i. Monitoring of Assigned Risk Producers: ARCS will be responsible for notifying the MAIP of ARP infractions that may result in the revocation of the ARP s MAIP certification as follows: (5) Failure to notify the ARC of any suspected fraud in the application for insurance or in the underwriting or rating process or in the payment of premium obligations or surrounding a loss; (6) Failure to assist the Servicing Carrier during any audit or investigation. 22

12 Premium/Application Fraud Common Scenarios Falsifying garaging location Failing to list operator Listing principal operator as occasional operator Failing to report any changes during the policy period including address changes or new operators that would increase the risk of loss. Neglecting to return the renewal application or statement of fact if required by the company. 23 MA Auto Policy Language (Massachusetts Automobile Insurance Policy, 2008 Edition, General Provisions and Exclusions, p. 28.) 24

13 Vehicle Usage Affidavit (personal lines) Client name policy number I am aware of the following language in my policy: If you or someone on your behalf gives us false, deceptive, misleading or incomplete information in any application or policy change request and if such false, deceptive, misleading or incomplete information increases our risk of loss, we may refuse to pay claims under any or all of the Optional Insurance Parts of this policy. Such information includes the description and the place of garaging of the vehicles to be insured, the names of all household members and customary operators required to be listed and the answers given for all listed operators. We may also limit our payments to those amounts that we are required to sell under Part 3 and Part 4 of this policy. Date Insureds Signature I understand if the usage changes, I will notify the above insurance agency so that an adjustment can be made to the policy. If I fail to notify the above insurance agency and a loss takes place, the insurance company may act in accordance with the above paragraph. 25 Vehicle Usage Affidavit (commercial Lines) customer name policy number I am aware of the following language in my policy: Except with respect to the coverages your are required to purchase in order to register your auto in Massachusetts, we may refuse to pay claims if any oral or written misrepresentation or warranty made in the negotiation of this policy by you, or on your behalf, was made with an actual intent to deceive or if the matter misrepresented or warranted increased the risk of loss. We may also limit our payments to those amounts that we are required to sell under Part 3 and Part 4 of this policy. Garaging Farthest location driven to 95 GMC 03 Chevy 07 SUV 08 Mercedes x date insured signature I understand if the usage changes, I will notify the above insurance agency so that an adjustment can be made to the policy. If I fail to notify the above insurance agency and a loss takes place, the insurance company may act in accordance with the above paragraph. 26

14 MA General Laws MGL Chapter 175: 186. Misrepresentations by insured; effect. No oral or written misrepresentation or warranty made in the negotiation of a policy of insurance by the insured or in his behalf shall be deemed material or defeat or avoid the policy or prevent its attaching unless such misrepresentation or warranty is made with actual intent to deceive, or unless the matter misrepresented or made a warranty increased the risk of loss. 27 Increase Risk of Loss Premium charged not commensurate with the risk undertaken Underwriting writes a policy that it would not have if it had the true and complete information Underwriting writes a coverage that it would not have if it had the true and complete information 28

15 Consequences of Auto Policy Fraud Deny all Optional Coverages: BI, Med Pay, Collision, Comprehensive, Substitute Transportation, Towing, Underinsured Recovery from insured of amounts that must be paid to a lienholder Reduce Compulsory Coverage to those limits that an insurer is required to sell by law Part 3---Uninsured Motorist---35/80 Part 4--Property Damage---$5k Collect back premium for compulsory coverage Cancel Policy 29 Help Prevent Premium Fraud Carefully review application/policy change request with your customer Prepare for the meeting with your customer by doing some pre work as suggested in the "Application Best Practice Guide" Ask your customers questions utilizing the "Application Best Practice Guide Encourage the customer to ask you questions if they are unsure of their responses Educate the customer as to the possible consequences of providing false or incomplete information 30

16 Help Prevent Premium Fraud Obtain policyholder signature on all applications and policy change requests Review the Notice of Information on the Application regarding false and deceptive information with the policyholder Conduct a visual inspection of the vehicle if driven to your agency. Look for old damage, broken glass, business lettering and verify that operator is listed Report to Underwriting any cases of suspected Premium Fraud Advise customer to verify information on the Statement of Facts and notify us of any changes 31 Help Prevent Premium Fraud Advise customer to review Coverage Selection Page each year at renewal Advise customer to report changes in circumstances to us as soon as possible Obtain photocopies of the licenses of the policyholder and each listed operator 32

17 Taking the Application 33 Applicant s Information Is address and/or mailing address correct? Is applicant a Massachusetts resident? If yes, they must have a Massachusetts license If not, is the vehicle utilized in Massachusetts in excess of 30 days per year? If not, applicant is not eligible for a Massachusetts policy. 34

18 Red Flags Red Flags that Apply to Applicant s Information Is never available to meet in person and supplies all information by telephone. Neither works nor resides near the agency. Has loss & violation history outside of the coverage venue. Gives a post office box in place of a residential address or mail must be sent to insured in care of another. Has lived at the address less than six months or has a history of being transient. 35 Red Flags Red Flags that Apply to Applicant s Information Has no telephone number or provides a pager number. Is reluctant to use the mail. Submits an incomplete, unsigned or backdated application. Has a problem remembering their date of birth or Social Security Number. Works through a third party. 36

19 Red Flags Red Flags that Apply to Applicant s Information Wants to pay premium in cash or to put as little as possible down. Suggests price is no object when applying for coverage but pays the minimum amount down. Has had a driver s license for a significant period of time, but never owned a vehicle or purchased insurance. Identification reflects different addresses than those shown on registration and title application. 37 Red Flags Red Flags that Apply to Applicant s Information Is insuring multiple vehicles yet there is only a single operator. Is unwilling to respond to questions concerning the ownership and principle place of garaging. Often questions the questions asked. Is reluctant to, or cannot answer questions about household members or others that may use the vehicle. 38

20 Red Flags Red Flags that Apply to Applicant s Information Applicant: questions agent closely on claim handling procedures or is overly familiar with insurance terms or procedures. has address discrepancies. (e.g. driver s license has one address yet applicant claiming another.) 39 Vehicle Information Principal place of garaging Where vehicle is most of the time that the owner/principal operator is asleep during the policy period If no principal place of garaging, residential address of operator If no residential address, Mass. business address Away-at-School scenario Principal place of garaging is school location Out of State scenario Affect on rating territory 9 40

21 Vehicle Information Special Equipment Anti-theft Affects discount Obtain certificate Annual Mileage Discount given on an earned basis RMV MI screen Yearly safety inspection indicates mileage Need to complete Annual Mileage form 41 Red Flags for Vehicle When inspected, vehicle was driven to site or your agency by unlisted operator. Vehicle is not available for inspection. Vehicle has unusual amount of aftermarket equipment (e.g. wheels, high priced stereo, and car phone) or receipts for aftermarket equipment are in another person's name. Vehicle inspection by agent uncovers discrepancy between Vehicle Identification Number listed on title/bill of sale, VIN plate on dashboard, and/or manufacturer s sticker on door. 42

22 Red Flags for Vehicle Remember: There are no letters O, Q or I in a VIN; There are numbers 0 and 1. Vehicle title or authenticated bill of sale cannot be produced. No Lienholder is reported for new/or high value vehicle. Loss payee is not a legitimate lending institution (e.g. bank or finance company)

23 45 Driver Information Who must be listed? All licensed household members who will operate the vehicle HH members who will not operate can be excluded via the Excluded Operator endorsement HH members with other policies can be deferred to those policies if the deferral is proper (see General Information section of the application) Anyone who customarily operates the vehicle (whether they live in the household or not) Gray area with regard to what constitutes customary operation 46

24 Driver Information What affects the premium? SDIP Driver Class Prime Factors affecting Class Experience (less than 3 years or greater than 6 years) Age Driver Education (inexperienced operators only) Business Use Date First Licensed Obtain copy of valid license Driver Training - Driver Training Certificate if Driver Information Percentage of Use Principal v. Occasional Measured relative to use of other operators Effect on rates--inexperienced principal operator charged more than experienced principal operator It does matter who owns the vehicle Massachusetts Residents If anyone who operates the vehicle is a MA resident who does not have a MA license, a policy should not be issued 48

25 Driver Information Failure to List Actionable if there is an increased risk of loss Unlisted operator is a higher SDIP Rating than other listed operators and/or Rating class would result in higher premium charged if listed Not actionable if no increased risk of loss SDIP Rating on same level or lower than other operator(s) and rating class would not result in higher premium or Operator could have been properly deferred to another Massachusetts policy 49 Driver Information An insurer can refuse to write physical damage coverages when the vehicle is: 1. customarily driven by or owned by persons who have within the last five years been convicted of vehicular homicide, auto insurance related fraud, or auto theft. 2. customarily driven or owned by persons who have within the last three years, been convicted of any category of driving under the influence of alcohol or drugs. 3. customarily driven by or owned by persons who, within three years preceding the effective date of the policy, have been involved in four or more at-fault auto accidents. An at-fault auto accident is one in which the owner or any person who customarily drives the auto was more than 50% at fault. From the 2008 Edition of the MA Auto Policy 50

26 Driver Information An insurer can refuse to write physical damage coverages when the vehicle is: 4. designated as a "high-theft vehicle" which does not have at least a minimum anti-theft or auto recovery device as prescribed by the Commissioner of Insurance. (Refer to Rule 23.) 5. customarily driven by or owned by persons who have two or more total auto theft or fire insurance claims within the three years immediately preceding the effective date of the policy. 6. customarily driven by or owned by persons who have within the last five years made an intentional and material misrepresentation in making claim under Collision or Comprehensive coverage

27 Foreign Licenses Persons with foreign licenses from countries that were parties to the "Roads Conventions" may legally drive for one year from the date of arrival in the U.S. A policy should not be issued if the person cannot provide proof that the license is valid. Acceptable proof is a stamp on a passport or visa or other proof that the person has left the U.S. and returned. Agent must verify eligibility utilizing RMV screens Required: Clear photocopies of the actual foreign license International licenses are not acceptable unless they are issued by the government agency that normally issues such licenses in the person's country of residence (a small number of countries do issue an international version of their licenses). International driving permits are not acceptable. 53 MA RMV Please note: An International Driving Permit cannot be converted to a Massachusetts Driver's License. An International Driving Permit does not confer any driving privileges but is a translation into ten major languages of the relevant information contained on the driver's home country license. An International Driving Permit must be issued by the person s country of residence. Caution: The Registrar and law enforcement agencies know that individuals or organizations have sold fraudulent documents as "International Driver Licenses" or International Driving Permits." The Registrar does not recognize as valid any Document purporting to be an "International Driver License" or any other document that confers driving privileges unless issued by the government agency that issues such licenses in the driver's country of residence and the driver is validly licensed. A person operating a motor vehicle with a fraudulent Massachusetts license is subject to arrest pursuant to MGL c. 90,

28 Verifying Licenses Verifying Out of State and Foreign Licenses: The Drivers License Guide Company issues ID checking guides for all U.S. states and most foreign countries ( The company publishes, among other guides, two guides (U.S. and Foreign) that contain pictures and descriptions of valid licenses. 55 Red Flags for Licenses Applicant cannot provide a driver s license or other identification or has a temporary, recently issued, out-of-state or driver s license from another country. Signature on license does not match signature on application. License appears tampered with or altered. 56

29 General Information Do you presently owe any motor vehicle premium, payable in the last twelve months? Has any automobile insurance policy been canceled or non-renewed for any reason? An insurer can refuse to write a policy if the applicant or any person who usually drives the vehicle has failed to pay an insurance company any motor vehicle insurance premiums due or contracted during the preceding 12 months. M.G.L. CH. 175 sect. 113H If the applicant has been in default in the payment of any premium for automobile insurance or merit rating surcharge during the preceding 24 months, the entire policy premium charges are payable in advance. 57 General Information Are any listed operators included on another policy or do they have their own Massachusetts personal automobile policy? If so and a premium is being paid on that policy for the operator, that operator can be deferred on this policy Deferral must be proper to a valid, active MA Policy Is any auto used to commute to work or school? Good opportunity to inquire as to location of work or school if applicant is claiming low mileage discount 58

30 General Information Is any auto used to transport: Fellow employees, passengers, or students for a fee? Persons employed by you? Is any auto used in Business? If van/pick-up, is it used to deliver/transport goods? Is gross vehicle weight 10,000 pounds or more and not assigned an ISO rating symbol? Both affect whether a personal lines policy should be issued. 59 Red Flags for General Info. Full coverage is requested for an older vehicle. No prior insurance coverage is reported although applicant s age would suggest the probable prior ownership of a vehicle. Unsolicited business. Application is processed at noon, end of day or business cycle or at other times when agent and staff may be rushed. 60

31 Premium Fraud Workshop Case examples of premium/application fraud using the Massachusetts application are included in your handout. Agents will work in a group setting to illustrate your understanding of the above information. CASE STUDY 1 Diana Long CASE STUDY 2 Todd Richards CASE STUDY 3 Raymond Smith CASE STUDY 4 Louidon Miller 61 Case #1 Diana Long

32 63 64

33 And the Answer Is 65

34 Case #1 - Diana Long Operator involved in loss not listed on policy Operator involved in loss has same residential address Operator involved in loss relation to insured husband with worse driving record than insured END RESULT Denial of Optional Coverage in claim and/or Policy cancellation for failure to list an operator 67 Case #2 Todd Richards

35 69 70

36 71 72

37 And the Answer Is Case #2 Todd Richards No date first licensed on application State of New Hampshire violations on MA RMV history Choicepoint history of licensure and violations in NH END RESULT Policy Cancellation for material misrepresentation of garaging and violations listed on the application 74

38 Case #3 Raymond Smith 76

39 And the Answer Is 77

40 Case #3 Raymond Smith Residence town different than mailing town. Territory is higher for mailing town Operators 1 and 2 same first name, same DOB, same SDIP step END RESULT This policy had a claim and the investigation proved that Raymond Smith and Raymond Jones were one and the same person. Denial of Optional Coverage in claim and/or Cancellation of Policy. 79 Case #4 Louidon Miller

41 81 82

42 83 84

43 And the Answer Is Case #4 Louidon Miller Change to mailing address. Territory is higher for mailing town. Change to mailing address completed within 2 weeks of effective date of policy Change to mailing address completed on same day as loss reported, two days after date of accident. Loss in same town as new mailing address Insured vehicle located in same town as newly listed mailing address. END RESULT Denial of optional coverage in claim and/or cancellation of policy. 86

44 Get a copy onto the office server for reference. 87 Summary Premium Fraud Premium Fraud results in lost premium dollars, higher rates, and claim denials. The agent taking the application has the best opportunity to recognize and prevent premium fraud before a loss occurs. The best defense: AWARENESS Fraud (Stealing) is not just a Claims problem; it is a problem the WHOLE Industry must fight Agents, Underwriters, and Claims 88

45 Claims Reporting Guidelines Note: Agencies should follow the instructions of their insurance carriers regarding the reporting of claims as many companies prefer the direct reporting of claims by policyholders. If the claim is reported to your agency the following guidelines will ensure that information important to the investigation of the loss is provided to your carrier. Notify the carrier as soon as a claim is reported. Do not delay reporting while waiting for further information. The goal is to have all new losses reported within 24 hours. 89 Accident Reports It is strongly recommended that you obtain the following information when reporting losses: Home, work, and cell phone numbers of the insured address, if available The location at which the car can be seen. Please include street address and telephone number if the car is located at a shop or tow yard. A detailed description of the loss Names, addresses, telephone numbers (day and night), dates of birth, and social security numbers of injured parties or other operators involved in the loss 90

46 Accident Reports Ensure that operators will be available for statements when required Ensure that the accident locus is specifically pinpointed in the loss report Ask the insured for the identity and contact information of all occupants and their placement within the vehicle at the time of loss (i.e. front passenger, backseat passenger left side) Location of the damage on the insured vehicle and whether any estimates were obtained Determine whether the police were at the scene and obtain specifics from the insured (i.e. officer name and badge #, police department and precinct) Ask the insured if there were any witnesses to the accident and obtain the contact information if available 91 Claim Red Flags Policy Coverage Loss on a new policy that was recently issued. Coverage minimal and exclude collision coverage. The coverage was changed just prior to reporting this claim. Policy in cancellation status. The insured has no record of prior insurance coverage yet the vehicle was purchased long before buying insurance on it. 92