Table III: Typical Policyholder Fraud Indicators
| Date(g): 18/12/2005 | Date(h): 18/11/1426 |
Table III: Typical Policyholder Fraud Indicators | |
| General Indicators | |
| Claimant’s Behavior | |
| General Conduct | ◄ Claimant doesn’t do anything to prevent or limit the damage |
| ◄ Claimant provides evasive answers and does not cooperate during a reconstruction | |
| ◄ Claimant gives inconsistent statements to the police, experts, and third parties | |
| ◄ Claimant hides details of claim to other people (e.g., family, friends, neighbors, etc.) | |
| ◄ Claimant handles business in person or by phone, while avoiding written communication | |
| ◄ Claimant displays detailed knowledge about insurance terms and claims processes | |
| ◄ Claimant checks the insurance coverage shortly before the claimed event | |
| ◄ Claimant modifies address, bank or telephone details shortly before a claim is made | |
| ◄ Claimant insists on using certain contractors, engineers, or medical practitioners without a convincing reason | |
| ◄ Claimant avoids giving information concerning denial of previous insurance when applying for a new insurance | |
| Coverage | ◄ Policyholder possesses several policies with the same insured object and coverage |
| ◄ Policyholder changes insurers frequently | |
| ◄ Policyholder insists on changing terms and conditions | |
| ◄ Claimant does remarkable filing of the claim (e.g., claimant seeks help of a lawyer or other professional advice in reporting the claim) | |
| Payment | ◄ Claimant requests that payment is made in cash |
| ◄ Claimant requests that payment is made into different accounts | |
| ◄ Claimant requests that payment is made to a third party | |
| ◄ Claimant insists that the payment exceeds the value of the damaged goods | |
| Speed of Settlement | ◄ Claimant insists on quick settlement of a claim |
| ◄ Claimant threatens to bring in a lawyer if the claim is not settled swiftly | |
| ◄ Claimant enquires frequently about the progress of the claim | |
| ◄ Claimant accepts a low payment to settle the claim quickly | |
| Claimant’s Characteristics | |
| Background Information | ◄ Claimant provides vague information regarding identity of policyholder and/ or beneficiary |
| ◄ Claimant uses a post office box or hotel as an address, moves repeatedly, gives false addresses, or has a non-matching telephone number and address | |
| ◄ Claimant refuses the disclosure of claims history with other insurers | |
| Personal and Financial Situation | ◄ Claimant has an usual and/ or difficult occupational situation (e.g., unemployed, self-employed, frustrated with job, facing disciplinary action, seasonal worker, or in an industry experiencing downsizing and lay-offs) |
| ◄ Claimant is experiencing a bad financial situation | |
| ◄ Claimant faces a difficult family situation (e.g., divorce) | |
| ◄ Claimant has a relationship with known fraudsters or criminals | |
| ◄ Claimant has a history in bad claims | |
| ◄ Insurer is experiencing difficulties reaching the claimant | |
| ◄ Claimant lives in a known fraud area | |
| Documents | |
| Forms | ◄ Application forms are incomplete and/ or unsigned |
| ◄ Claim forms are incomplete and/ or unsigned | |
| ◄ Claim forms are modified frequently | |
| ◄ Application form and the inception date of the cover are different | |
| ◄ Application form and claim form are inconsistent | |
| Receipts and Reports | ◄ Minor losses are sufficiently documented while major ones are not |
| ◄ Documents/ receipts are unspecific, modified, or unreadable | |
| ◄ Original documents/ receipts are missing; only copies are provided | |
| ◄ Receipts are new (e.g., not wrinkled, clean) for old events or products | |
| ◄ Receipts contain different handwritings | |
| ◄ Documents display odd dates (e.g., during holidays, after business hours etc.) | |
| ◄ Doubtful receipts are provided, from companies that do not exist, have ceased operations, or are insolvent | |
| ◄ Doubtful receipts are provided, with differing dates but with successive numbering | |
| ◄ Foreign receipts contain unspecified currency | |
| ◄ Reports from medical practitioners or other authorities (e.g., police) are inconsistent | |
| ◄ Documentation from foreign countries is different from the expected format or content (e.g., use of incorrect language) | |
| Claims’ Characteristics | |
| Submission of Claim | ◄ Claims are submitted by a third party without proper power of attorney |
| ◄ High claims are submitted frequently | |
| ◄ Claims submitted display prevailing connections | |
| Timing of Claim | ◄ Claim is filed in one of the following cases: - Shortly after coverage becomes effective. - Just before cover ceases. - Shortly after the cover has been increased or the contract provisions are changed. |
| ◄ Loss occurs just after payment of premiums that were long overdue | |
| ◄ Damage occurs in the period of provisional cover | |
| Size of Claim | ◄ Loss is actually far higher than first reported |
| ◄ Loss claimed is just below the threshold that causes additional checks by the insurer | |
| ◄ Amounts insured and the characteristics (e.g., age, profession) or life style of the policyholder are inconsistent | |
| Indicators Specific to Business Classes | |
| Property claims (including disaster fraud) | |
| General Property Losses and Claims | ◄ Losses and the characteristics (e.g., residence, occupation, income, lifestyle, etc.) of the policyholder are inconsistent |
| ◄ Claimed losses and the findings in the police report are inconsistent | |
| ◄ Damaged items cannot be/ are not examined by loss adjusters | |
| ◄ Destroyed items are in bad shape | |
| ◄ Large amount of cash is stolen | |
| Fire | ◄ Fire affects a single property or building without affecting others |
| ◄ Policyholder, family and pet are absent during a fire | |
| ◄ Items of sentimental value (e.g., photograph albums) or family heirlooms are not lost or damaged during fire | |
| ◄ Absence of physical evidence of the place where heavy items were located (e.g., indentations in the carpet from furniture | |
| ◄ There are multiple sources of fire | |
| ◄ Origin of fire is unknown | |
| ◄ There is no evidence of burglary in case of arson | |
| ◄ Building is unoccupied and without surveillance at the time of fire | |
| ◄ Building is disconnected from public utilities at the time of fire | |
| ◄ Fire is not detected by fire alarm | |
| ◄ Fire alarm is switched off coincidently | |
| ◄ Fire alarm is switched on, but blocked by objects | |
| ◄ Fire is detected shortly after people leave the building | |
| Car Accidents | ◄ Car damage and/ or injuries are exaggerated, claims are fabricated or accident is staged |
| ◄ Circumstances of accident are identical as a previous claim or with the same lawyer | |
| ◄ Blame on the accident is accepted too easily | |
| ◄ Police and/or emergency services are not contacted immediately after an accident with substantial damage | |
| ◄ Claim for recovery damage is not made immediately after an accident with substantial damage | |
| ◄ Relationship exists between the people involved (e.g., between passengers of the different vehicles, between patient and doctor, etc.) | |
| ◄ One of the individuals involved has a rental car | |
| ◄ Driver of the rental car accepts blame easily | |
| ◄ Eye witness is very cooperative | |
| ◄ One of the vehicles involved in the accident is old and the other is new | |
| ◄ Severe damage occurs without a collision (e.g., swerving) | |
| ◄ Both people involved are foreigners from the same country | |
| ◄ Claim involves victims with no own damage insurance and/or one who would be at risk if found at fault | |
| ◄ Testimonies are very similar or strikingly different after an accident | |
| ◄ Reported injuries are remarkably similar | |
| ◄ Damage does not match the injuries (e.g., little physical damage but severe personal injuries) | |
| ◄ Inconsistencies in the damage of the cars involved (e.g., one with minor damages, the other with severe damages) | |
| ◄ Injuries are difficult to observe objectively (e.g., headaches or whiplash) | |
| ◄ Marks at the location of the accident are absent or difficult to find | |
| ◄ Accident occurs in a deserted location | |
| Car Theft | ◄ Vehicle has an unusual registration number |
| ◄ Vehicle has been registered very recently | |
| ◄ Vehicle is stolen just after the end of the “new-value period” | |
| ◄ Registration certificate is inside the vehicle or is lost before the theft | |
| ◄ Vehicle keys are not the original ones | |
| ◄ Vehicle alarm is switched on but does not work | |
| ◄ Stolen vehicle is recovered completely undamaged | |
| ◄ Stolen vehicle is recovered with valuables/ documents | |
| ◄ Age or social position of the insured and the make and model of the vehicle are inconsistent | |
| Claimants Conduct and Employment Information | ◄ Losses are described vaguely |
| ◄ Claim is filed with delay | |
| ◄ Items are over-insured substantially | |
| ◄ Claimant gives very detailed description of the property or a detailed photo report at the preliminary stages of the claim | |
| ◄ Lists of property in the claimant’s and the loss adjuster’s reports are in the same order | |
| ◄ Items insured are new according to the claimant | |
| ◄ Inconsistencies exist in the claimant’s account | |
| ◄ Claimant does not want the claim handler to contact his employer directly | |
| ◄ Claimant’s employment information is suspicious | |
| ◄ Claimant started his employment shortly before the accident occurred | |
| Police Reports | ◄ Police report is not provided when expected |
| ◄ Discrepancies exist between the claimed losses and the findings in the police report | |
| Travel | |
| Timing | ◄ Loss is reported a long time after the trip |
| ◄ Mismatch exists between insurance term and holiday period | |
| Life | |
| Policyholder Information and Conduct | ◄ Relationship between the policyholder, the insured and the payer of the premiums is unclear |
| ◄ Policyholder or beneficiary owns several policies with different addresses | |
| ◄ Policyholder accepts unfavorable conditions | |
| ◄ Insured amount and standard of living of the policyholder are inconsistent | |
| Payments and Beneficiaries | ◄ Payments are requested to be made to others rather than the policyholder or the beneficiary |
| ◄ Premium is paid in cash | |
| ◄ Premium is made in foreign currencies or from a foreign bank account | |
| ◄ Payment is made to unrelated third parties | |
| ◄ Policyholder and beneficiary have a significant age difference | |
| ◄ Beneficiaries of policy are frequently changed | |
| ◄ Beneficiary’s name and account number are inconsistent | |
| Cancellation of Policy | ◄ Request for cancellation of policy or refund of premiums are made shortly after the cooling off period |
| ◄ Request for cancellation is not signed or signed by an unauthorized third party | |
| Time and Place of Death or Claim | ◄ Claim of suicide or a criminal offence is made shortly after inception of the policy |
| ◄ Change of policy provisions or beneficiary is made just before death or disability | |
| ◄ Insured is claimed dead while abroad | |
| ◄ Disability claim is made just after a premium default | |
| Missing Death Information | ◄ Body of deceased is missing or unidentified |
| ◄ Original death certificate is unavailable | |
| ◄ Cause of death or disability is suspicious | |
| Transport | |
| Operations | ◄ Weighbridge is non-calibrated |
| ◄ Goods are delivered after theft | |
| ◄ Drivers are paid per trip | |
| ◄ Documents are handled without sufficient supervision (e.g., in hotels, restaurants) | |
| ◄ Goods are transported to a destination that does not have a market or proper processing facilities | |
| ◄ Goods are repacked to larger volume entities | |
| ◄ Goods destined to developing countries are over evaluated | |
| Inconsistencies | ◄ Inconsistencies exist between insured volume/weight and the real weight |
| ◄ Inconsistencies exist between the insured volume/ weight and the type of goods | |
| ◄ Inconsistencies exist between the insured amount and market prices | |
| Related Parties | ◄ Parties involved have a bad reputation in the business |
| ◄ Endorser is different from claimant | |
| ◄ Intermediaries are non-cooperative | |
| Healthcare | |
| Conduct of Claimant | ◄ Physicians are changed frequently |
| ◄ Claimant has multiple disability policies | |
| ◄ Claimant claims a disability and is involved in active employment or in a physical sport or hobby | |
| ◄ Claimant develops additional injuries allegedly related to the initial injury or illness when it appears that the claim will be terminated | |
| ◄ Claimant’s illness or injury occurs shortly before an employment problem (e.g., disciplinary action, demotion, layoff, strike, termination, or down sizing) | |
| ◄ Claimant visiting more than two medical providers for the same case | |
| Conduct of Physicians | ◄ Emergency services are not contacted |
| ◄ Prescriptions are cut or altered | |
| ◄ Documents contain misspelling or misusing of medical terminology | |
| ◄ Improper identification numbers are used | |
| ◄ Attending physician is not in the same geographic region as the claimant | |
| ◄ Incorrect or conflicting diagnosis from different medical providers are given | |
| ◄ Treatment provided to the claimant is inconsistent with the report diagnosis | |
| ◄ Treatment is scheduled on holidays or other days when medical facilities are normally closed | |
| ◄ Attending physician’s specialty is not consistent with the diagnosis | |