It’s not true that insurance carriers are averse to paying claims, it’s just that many insurers hate paying claimants that don’t deserve the money—particularly those who file fraudulent claims that end up costing honest policyholders in the long run.
Tim Wolfe heads the special investigations unit (SIU) for CNA where his team’s responsibility is to detect and investigate claims fraud. To assist in that job, CNA began using the Fraud Framework tool from SAS in 2011 after taking several years to vet suppliers of similar tools and go through pilot programs to select the best tool for the carrier’s business.
The SAS tool allows CNA to see connections between claims. For example, the same doctor and attorney may be representing multiple claims. Those claims might be handled by individual adjusters who might not be able to connect the dots. The tool connects those dots and looks for patterns of questionable activity.
CNA applies its own business rules, which are available in the data fields. Wolfe explains an example of this might involve a property claim where the carrier can list some of the factors that the tool needs to consider.