Filed Under:Claims, Investigative & Forensics

Featured Fraud: It All Adds Up

It is not uncommon to hear of criminals being discovered because their stories just “don’t add up.” In this case, the stories of 32 people did add up … to a whopping $3 million in fraudulent insurance payouts.

A recent FBI-led investigation in South Texas dubbed “Operation Sitting Duck” led to the indictment of 32 people on federal insurance fraud charges. Between 2001 and 2010, approximately 21,600 purportedly fake claims for minor injuries and accompanying doctors’ accident reports were submitted to AFLAC in a scheme involving those 32 people.

Investigation revealed that two unnamed doctors at a Reynosa, Mexico family clinic were signing off on fake accident reports, receiving $10 to $15 for each alleged injury, and instructed the fraudsters to avoid requests from the insurer for X-rays or medical tests. According to the indictments, compensation for each claim ranged from $100 to $500.

What made this situation unique was the use of AFLAC’s accident-only insurance plan. Different than primary medical insurance, this policy is supplemental and covers costs after unexpected injuries when a person is unable to work.

Among those indicted were a police officer, county employees, and schoolteachers.

According to prosecutors, anyone convicted will be required to pay back fraudulently obtained funds. Additionally, those convicted face up to 20 years in prison and a $250,000 for each count of conspiracy and wire fraud.

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