Facts of Loss Red Flags

 

June 15, 2015

 

Fraud can be easy or difficult to determine, depending on the expertise of the person committing the fraud. The use of a checklist to review the claim and spot red flags can be the first step in identifying a potential fraud claim so that it can be passed on to investigators to determine what actually happened. The following checklist relates to the facts of the loss; presented are indicators that things may not be as they seem. More than three checks indicate that referring the claim to the investigators is a good idea; it may not be fraudulent, but it should be further investigated.

 

____Witness version does not agree with claim as presented

 

____Presence of an overly enthusiastic witness at the scene of the incident

 

____No police report

 

____All injuries are subjective.

 

____CPT codes appear inflated or "up-coded."

 

____Losses occur just after coverage takes effect.

 

____Losses occur just before coverage ceases.

 

____Losses occur just after coverage limits have been increased.

 

____Losses include a large amount of cash.

 

____Commercial losses include old or non-saleable inventory.

 

____Building is in deteriorating condition.

 

____Building is located in a deteriorating neighborhood.

 

____Fire scene investigation suggests property or contents were heavily over-insured.

 

____Fire scene investigation reveals no remains of noncombustible items of scheduled property.

 

____Fire scene investigation reveals no remains of expensive items used to justify an increase of limits.

 

____Fire occurs at night.

 

____Fire occurs after 11 p.m.

 

____Commercial fire occurs on holiday, weekend, or when business is closed.

 

____Fire alarm fails to work at time of loss.

 

____Sprinkler system fails to work at time of loss.

 

____Insured over-documents losses.