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Insurance Fraud Investigations - Latest Innovations Add Sheen To Insurance Fraud Investigations


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A request for conducting insurance fraud investigation is made for by either of the two parties to an insurance policy, viz. the consumer and the insurance company, when one of the two parties feels that the other party has committed a breach of contract, or the contractual obligations agreed to between the parties have not been fully met.

There are a number of insurance schemes offered by the insurance companies to the consumers including medical insurance or health insurance, automobile insurance, life insurance, crop insurance and such other types of insurance.

The opportunity for fraudulent activities in insurance industry is more as the room for making quick money is more. For instance, in the US, it has been estimated that as much as $80 billion is paid out every year towards fraudulent claims.

The role of insurance fraud investigations is crucial in assessing the validity of the claim, discouraging fraudulent claims and bringing the culprits to court, and providing relief to the aggrieved parties.

The type of investigations being carried out for each type of insurance varies in type and analysis. In the case of medical health insurance frauds, insurance fraud investigations are carried out from the database to get hold of the medical history of the client~{!/~}s service history records. The pattern of billing of the medical health practitioner is examined in detail to find out for any anomaly in the billing. A detailed study of the service records, in most of the cases in medical health insurance fraud investigations, reveals that the practitioner had created or re-created the client service records to falsify the accounts, increase the number of visits made by the clients for seeking consultations, thereby indulging in increasing the revenue per visit from the client, and indirectly increasing the market price of the client visits to the medical practitioners.

With regard to auto insurance fraud claims, the insurance fraud investigations are centered around the damage estimates and claims filed in the claim form. The insurance fraud investigations will then be concentrated on the comparison of the claim with similar claims in the past that were available in-house in the investigator~{!/~}s office. The type of damages claimed for the vehicle and the amount charged for repairs for the vehicle, quoted by the auto mechanic, also offers valuable clues with regard to the damages, when compared with similar case histories from the databank available at the investigations house.

The sophisticated methods employed by the investigators in investigating frauds related to insurance frauds have resulted in decreasing the time lag between the lodging of the claim and the delivery of verdict. However, the prevalence of insurance frauds in the industry, on the whole, has been rampant, considering the lure of quick money, which is available in the insurance industry.

It is advisable for both the consumers as well as the insurance companies offering policies to the consumers to act in accordance with the rules and regulations that are in vogue in the region, and avoid insurance fraud investigations.

Francisco Segura owns and operates

Insurance Fraud


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