Insurance Claim Investigations

Dion Neill is a former Certified Fraud Examiner with decades of experience investigating insurance claims. Dion was one of the first private investigators in New Zealand to conduct investigations on behalf of the Accident Compensation Corporation (ACC).

Dion has successfully detected and investigated claimants who have acted dishonestly to gain a personal or financial advantage.

Our fraud investigation specialists can assist you to confirm the validity of insurance claims or to investigate a claimant who is suspected of misrepresenting information. Injury and disability insurance claims can amount to a substantial amount of money.

Insurance companies often conduct claims investigations to evaluate the legitimacy of a claim. The investigation process helps the claims adjuster make an educated decision about how to proceed with a claim.

Insurance claims investigations are used to combat the prevalence of false or inflated claims. An illegitimate claim is unjustifiable or inaccurate, and by identifying it early you avoid paying potentially significant costs to a fraudster.

Insurance claims investigations rely on evidence, interviews, and records to conclude whether a claim is legitimate or illegitimate.

Workers’ Compensation Claims (ACC)

Fraudulent workers’ compensation claims can be hazardous to the financial wellbeing of your business. To determine the legitimacy of a claim, an examiner will conduct a workers’ compensation claim investigation.

The investigation seeks to determine two things:

  • Is the employee as injured as they claim to be?
  • Was the injury acquired while the person was working?

For example, an employee who is injured outside of work Tuesday night but comes in the next day and files a claim indicating that the injury happened at work would be filing a fraudulent workers’ compensation claim with ACC or a personal injury insurance company. Investigations often reveal the truth.

Personal Injury Claims

Fraudulent personal injury claims can be equally as hazardous as fraudulent workers’ compensation claims. Personal injury claims can be filed against either a business or against another person. The claim becomes fraudulent when the victim actually fell down their own steps but staged the incident to look like it occurred at a workplace.

Property Damage and Theft Claims

Insurance companies will also investigate property damage (e.g., fire damage, water damage, or motor vehicle accidents) and theft claims (e.g., theft, burglary, or robbery). Depending on the property and the insurance claim, a private investigator may employ a recognised expert. For example, they might ask for someone to come in and evaluate the burn patterns to discover the origin and cause of a fire.

The information gained through this process will help the examiner either confirm or deny that the claim is legitimate.

Healthcare & Medical Fraud Claims

These claims are investigated by private insurers and public ones (ACC). In some cases, a patient may work with their medical practitioner to fake or inflate a claim.

Claims Investigation Process

The claims investigation process is similar to other private investigations. It involves many steps, such as collecting and reviewing documents, taking statements, locating and interviewing witnesses, inspecting and photographing the damaged property or accident site, conducting surveillance, and analysing social media accounts.

Collecting and Reviewing Documents

During our insurance claim investigation, we request and collect official records stemming from the injury or damage. For a personal injury claim, we can seek out official records created by the hospital or victim’s doctor. We ask for medical release forms, prescription records, doctor’s notes, or any documents that could confirm the legitimacy and severity of the injury.

For a property damage claim from a vehicle accident, request a copy of the police and accident report. These reports will have information from the day the accident was reported and can be used to corroborate statements and details obtained through interviews.

For a property theft claim, request receipts of the stolen item or photos proving the stolen item belonged to the victim. Sometimes a true victim of property theft will start padding their claim with additional items they didn’t really own. Asking for proof of ownership will often help prevent exaggerated claims.

Taking Statements and Interviewing

Depending on the claim, the questions we ask will differ. In a theft claim, ask what items were taken, when they first realised something was amiss and the names of any people who were in the home around the time of the theft. Read the original police report aloud and monitor how the claimant responds.

Request a recorded or written statement from all involved parties describing the incident and circumstances. Being able to hear or read the statement at a later time will make it easier for you to compare future information to what was said.

Surveying the Area and Claimant

Take photos or videos that will help the story make sense. Depending on the claim, we take photos of the location (workplace, home, vehicle, intersection) and the injury itself. Having access to a permanent, physical view of the environment will help you make sense of what the statements and official records say.

We conduct surveillance. If an employee claims they slipped on the steps of their workplace and injured their back, we may spend time carrying out surveillance to ensure their movements are consistent with their injuries or disability.

Obtaining Other Contextual Information

We consider other contextual information that will help understand the claim. We check a claimant’s social media accounts to learn more about them and the situation. Recent posts about struggling financially or hating work might raise suspicion. Posts about playing sports might cast doubt on an injury claim.

We search claim history, perhaps they claimed for the same injury in the past? Perhaps the last insurance claims investigation proved the insurance claim was fraudulent. A discovery like this may sway the outcome of the investigation.

Leave the investigation to us, we are the recognised investigation professionals.