NICTA Customer Service & Fraud Investigation
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1 NICTA Customer Service & Fraud Investigation SCENARIOS The following scenarios provide circumstances where questionable aspects of an insureds claim have to be addressed. In some instances your company s claims handling practices may not match the details of the scenario. For example what to do when an insured wants to talk to a manager will differ between companies as well as how to introduce a Reservation of Rights letter. The scenarios are not meant to dictate your claims handling process. They are meant to illustrate possible approaches and responses when dealing with a questionable claim. It is understood they may not match the claims handling practices of your specific company. This also applies to the position of the insurance person involved in the scenario. Depending on the company it may be a first notice of loss person, a claims adjuster, an appraiser, a SIU, a manager or an attorney. Therefore the potential approaches and responses are not assigned to a specific role but are generically delivered. When there is a company conflict with the scenarios, adhere to your company s policies. The scenarios provide situations involving an insured and a possibly fraudulent claim. Approaches and example language are provided to demonstrate how the situation can be potentially addressed and still have the insured be satisfied with their level of customer service. Of course, not every possible situation can be specifically addressed in the following scenarios, but the approaches and example language provided are adaptable and can be used in situations with different circumstances. As mentioned previously, satisfying a customer is most easily achieved when they understand the process and actions being taken by using explanations that indicate a potential benefit to the insured and that are completely truthful. As with any interaction with the insured, preparation is important. Providing good customer service is no different. It is best to anticipate the insured s reaction and the questions they may have concerning your requests and to have your responses ready. It is also vitally important that communications and expectations be documented. Approach every interaction in a courteous and respectful manner. When appropriate, offer the customer an opportunity to explain any conflicting evidence or facts. Explain you are providing this opportunity to allow them to supply additional information or clarification. This in itself provides customer service. Please note, this course is not meant to supersede, change or replace existing company policy. In situations where the course content conflicts with your company s procedure, please adhere to your company s position.
2 During initial or early contact with the insured: WITH THE INSURED When taking the initial statement/facts of loss/proof of loss the insured appears to be hiding or not providing necessary information. Potential approach - Explain we need the supporting information/documentation so the claim decision can be made in a timely manner on your behalf. Without the documentation to support your claim, we are not in a position to make a claim decision on the items you are claiming but can t provide documentation for (allows the insured to reconsider). The insured has provided questionable documentation/information (circumstances, altered copies, appears fake) Potential approach Explain you ve received the documentation (or information) and are in the process of reviewing them/it. To assist with the claim you may ask a co-worker (provide name) to help review the documentation/information the insured has submitted (opens the door to introducing additional investigation). If asked why the co-worker is needed Potential response The information/receipts need to be verified and before coverage can be provided. My co-worker will work with you to verify the information/documentation and this will expedite the process. The insured wants to talk to the manager because of what you are asking for Potential response Please understand I need this information to evaluate your claim and my manager is going to ask you for the same information. If the insured persists, let them know your manager will contact them. Contacting the insured after they have spoken with your manager Potential approach I hope speaking to my manager has helped you understand the situation. Have you been able to obtain the documentation/information we need to move your claim forward (This puts the responsibility back on the customer letting them know they need to assist and cooperate in order for their claim to reach the correct resolution)?
3 Where there are indicators of fraud very early in the claim process: Potential approach Explain it is company procedure to go over the policy details with the insured before the claim is processed. Then go over deductibles, exclusions, fraud provisions, reporting, etc. This allows the insured to reconsider their position (and hopefully change their mind) before actually committing any fraud. An example would be where the number of items lost in a home burglary appear to be inflated (many more items than on the police report or a supplemental claim). Before asking the insured to verify they had these losses, state that it is company procedure to review the policy information concerning coverage, deductibles, exclusions, requirements to cooperate, how the entire claim can be denied if any part of the claim is found to be fraudulent, how they may have to provide an examination under oath and how the state requires questionable claims to be referred to the state fraud bureau for investigation and possible prosecution. Then end by asking if the insured understands all of the policy details before starting to discuss the loss statements. Where the insured states they didn t know about the deductibles, exclusions, coverage requirements or duty to cooperate: Potential approach - Explain to the insured how the claim investigation process works and what applicable deductibles/coverage s will apply. Further explain that these provisions are designed in the best interest of the policyholders to keep down premium rates by offering the policyholders options in the deductible amounts, by removing the worst risks from their premium calculations (exclusions), ensuring proper safeguards (e.g. requiring scheduled property to be vaulted, etc.) and making sure only losses covered by the policy are paid for (cooperating by requiring proof of ownership, allowing inspections, EUO s, etc.). Where more information or documentation is needed because of questionable items in the claim and the insured is questioning the need for the extra info and paperwork: Potential response - State you are trying to resolve the claim in the best interest of the insured and it is necessary for them to provide additional information in order to validate the items being claimed. Without the required supporting documentation you are not in a position to make a decision on the claim in regards to coverage.
4 Lack of documentation: The insured says there is no documentation Potential response - If you don t have documentation, we can help you obtain it. Please tell me where you purchased it and your form of payment - cash, check, debit card, etc. (this may also be a good opportunity to ask for permission to obtain their financial records)? If insured states they can t remember the purchase location Potential response it is a policy requirement for you to provide supporting documentation for your loss. If we can t verify your loss it will delay your claim and we may not be able to pay your claim. The insured provides partial documentation Potential response We will be able to work with items you have documentation for, but will need documentation for the other items in order for them to be considered. If jewelry loss without documentation Potential response - To help you we may be able to accept any pictures you have where you are wearing the jewelry. Also ask where purchased and if a gift, ask who gave it to them and for any appraisals. Where the property appraisal/damage assessment process reveals questionable activity: Note: If the insured did nothing wrong (e.g. staging the loss) they should, in most cases be open to the extra measure taken to be sure everything is handled appropriately. Potential approach - Explain to the insured that further investigation is necessary to ensure the damages correlate with the reports facts of loss. Also explain you need to verify that there was no pre-existing damage to the property in question. Let the insured know you are doing what we can to help them by verifying the damages. This may include an in-person interview or property/scene inspection to help gather all the facts. It will help you in determining the causation of any losses being alleged Where questionable activity on the part of a contractor/public adjuster is suspected: Note: This type of approach is useful in claims involving public adjusters and/or water extraction companies, smoke and ash cleaning companies, auto glass repair companies as well as home repair contractors, etc. Potential approach Advise the insured that you are investigating their claim as information has been received indicating that there are dishonest contractors/public adjusters/vendors in the area creating false damage/claims. We re investigating claims associated with them to make sure you (the insured) is not being taken advantage of by dishonest contractors/public adjusters/vendors. This investigation will assist them and others.
5 Where a medical condition/injury is questionable: Note: When an insured or any customer is being honest in their dealings with the insurance carrier usually they will understand the need to determine the nature of the injury, pre-existing medical conditions, etc.. However, interacting directly with the injured person may not be possible if they are represented by an attorney. Potential approach - Incorporate portions of the previous response (contractor/public adjuster) but explain the exposure to the insured regarding deductibles and co-pays. If it is determined that a service was rendered that is not related to the injury in question the carrier will not owe it but nor will the patient, thus a savings to all parties. Where the insured does not cooperate: Potential approach - If you receive information the insured refuses to provide a statement or to cooperate, send a letter encouraging the insured to reconsider so their claim can be properly resolved. This information may be included in your company s reservation of rights letter. When introducing the Reservation of Rights (ROR) letter or the non-waiver Agreement: Potential approach - Explain that a ROR letter (or a non-waiver agreement) doesn t mean the claim isn t covered. It tells the insured that coverage is in question for a portion(s) of or the entire claim. When completing an ROR be specific as to the issues that are in question. Example: When questionable vehicle damage or injuries are not consistent with facts of accident or an excluded driver had the vehicle when involved in an accident or it was stolen. Explain the ROR letter is just informing the insured of the company s rights. The ROR helps protect the insurance company as most ROR letters state We are investigating this claim but preserve our right to later deny coverage if investigation shows that this is not a covered loss."
6 Where the insured is questioning why other insurance personnel (e.g. SIU, IME, biomechanical engineer, building inspector, etc.) are involved: Potential approach - While it s very important to be forthright with the insured concerning why other personnel are involved, it is best not to indicate that fraud is suspected and instead provide an alternative and accurate reason. Potential responses - There has been conflicting information from different sources and we re trying to establish the facts in order to provide the best possible resolution of the claim for you (the insured) under the conditions of the policy...or explain that your duty as an insurance carrier is to complete a thorough investigation and gather as much information from all sources possible. These additional personnel will help you do that. Advise that they are there to verify information as well as attempt to investigate any questionable information...or we are making an extra effort to verify the billing is accurate...or we try to provide in person customer service whenever possible to aid in the resolution of the claim. or we have a responsibility to you and to all our insureds to ensure that the supporting documentation presented is properly reviewed and verified...or you made an excellent decision to employ us as your insurer and we are fulfilling our obligation to you by properly evaluating the merits of this claim.
7 When an in-person interview is required: Note 1: In all situations where an in-person interview is required your individual safety must be the priority. The location of the meeting must be carefully considered as well as who will be present besides the insured. Several items concerning the safety of an in-person meeting must be evaluated prior to the meeting being conducted (see the NICTA course Field Safety). Note 2: The insured may feel frustrated or upset. Don t let the insured s emotional state cause you to get angry or respond in the same manner. Note 3: Make sure you are referring to the correct policy and/or sections. When misrepresentation is suspected Potential approach Introduce yourself as working on the claim to help gather the facts to assist in evaluating the claim. To do that I need to do an in-person, recorded interview with you (establish neutral location if necessary, time, date). If the insured is resistant Potential response We re unable to process your claim until the interview is conducted, so in order to move forward we will need to meet and clarify the information submitted to date on your claim. If the insured refuses Potential response I understand your frustrations and this process is for your benefit. The policy requires your cooperation (point out to them the appropriate policy sections). Your claim won t be resolved until you help us clarify the information you ve submitted. If you refuse your claim may be denied because of your decision not to cooperate. If the insured asks about getting an attorney Potential response I can t advise you, that is a decision you have to make. If you choose to, please have them contact me (provide contact info) right away so I can schedule your interview through their office. You are being questioned by the insured on the progress of the claim: Potential response tell them you still need information/documents/releases (if you do) and ask them if they have anything else to support the claim. Tell them they will be contacted with a claims decision if they don t have anything else to support their claim. If they say they will or have provided additional information let them know you will follow up on that and will get back to them.
8 You have proven inconsistencies and want to introduce a withdrawal form: Potential approach - Show the insured the inconsistencies you ve identified and go over the facts with them. Let them know the information they provided is not accurate and ask them if they can explain why (making sure you have the facts proving the inaccuracies)? If they can t explain, tell them you have to report the inconsistencies. Inform them if they wish to stop the claim process, knowing you have established an attempt to commit fraud, they can voluntarily withdraw their claim by completing this form. Please ensure they are aware you are required by state legislation to refer matters of fraud to the appropriate department or board (in states where appropriate). Where the insured indicates they may want to withdraw their claim: Potential approach - Discuss their option of voluntarily withdrawing their claim if they wish to. No promises are made in exchange for the withdrawal. Explain it does not take away your duty to refer the matter to the DOI (if required to do so) regardless of the claim being withdrawn...or explain it s their right to withdraw their claim, it s a decision they have to make (if your state requires suspected fraud be reported to the state inform them of that). If partial payments have been made or if the insured is trying to withdraw part of the claim, inform them additional actions may be taken by your company.... or once the investigation has obtained substantiated evidence that the claim is not valid or has documentation or statements that are inconsistent they can discuss inperson with the insured the information obtained. At that time, the insured can be advised he/she has two options, proceed with the claim and clarify the questionable items or withdraw his/her claim... or ensure that the document is explained clearly to the person. Document the conversation on the record (e.g. recorded statement or in writing) so as to protect the insurance carrier from any allegations in the future on how the withdrawal was obtained. Where an examination under oath (EUO) is being requested: Potential approach - Explain to the insured there are inconsistencies and issues with their statements and information they have provided (to the police, investigator, agent, etc.) and an EUO will help clarify the issues and inconsistencies. In your conversation with the insured make them aware the EUO is a policy provision and the right of the insurer to request it. Follow-up the conversation with a formal letter requesting the EUO and quote the policy language (letters requesting EUO s are often done by staff or counsel). When the insured is complaining of poor customer service and threatening to take their business elsewhere: Potential response - We are committed to a fair claims process. We value your feedback and are doing everything we can to resolve your concerns. All insurance companies follow specific guidelines to make sure that the needs of the customer are met, while working with the agreements stipulated in your contract.
9 WITH INDIVIDUALS OTHER THAN THE INSURED Note 1: Please remember that others we speak with are potential customers of our company or could already be a customer and observing how we deal with claims and communication, etc Therefore, the manner by which we interact with other parties is equally as important as the manner in which we interact with our own insured. Note 2: It is recognized that in some instances other individuals may be suspected of being in collusion with the insured and the potentially fraudulent activity. If it s suspected the individual (s) may intentionally provide misleading information, interviews can be deferred and other means of verifying the needed information utilized. Where an agent/broker suspects questionable activity by an insured: Potential approach - Be very limited in conversations with the agent in regards to accusations against the insured. Avoid putting the agent in compromising position with their client. Be aware you do not know the relationship between the agent and the insured. Thank the agent for the information and advise them the situation will be looked into further and an investigation will be conducted if necessary. If so we will handle the investigation appropriately but may need to speak with the agent in the future for a statement, documents, etc. Where the agent/broker is complaining on the behalf of the insured or you contact the agent/broker for information: Potential approach - In these cases the agent is almost always going to ask why his client has to provide additional information or documents and/or why additional investigation is being conducted. It is usually best to use the same approach as you would with the insured. Avoid any language implicating fraudulent activity and provide an explanation showing the extra investigation/steps are a potential benefit to the agent s client. For example, tell the agent that their client s claim can t be processed until the additional information or documents are obtained. Any assistance the agent can provide would be helpful in resolving the claim. Where the investigation includes interviewing witnesses, neighbors and other non-insureds (retail stores, body shops, etc.): Note: There is no need to advise the insured or other parties of this part of the investigation. If the insured being investigated did indeed do something illegal he/she may try to speak with these potential sources before you do in an effort to persuade them not to talk to you and not to cooperate. You are not obligated to advise the insured of the steps of your investigation. If the insured asks about these interviews Potential response - Advise the insured that interviewing the neighbors (or others) will assist in establishing a time frame or other information concerning the loss. For example if some type of theft occurred the neighbors may have seen the suspect or a suspect vehicle and might be able to provide valuable information for the police. If an injury is involved other information could be gained that may help with the insureds claim
10 Where interacting with an attorney who is representing the insured: Note 1: Some claims involving unmeritorious activity, especially as it relates to injury claims, may also have an element of unscrupulous behavior on the part of the attorney. Note 2: Be very cautious when discussing any claim information with anyone who indicates they are working for the insured/claimant or representing them. Ensure you have the proper documentation verifying they are authorized to represent the insured. Potential approach - Above all else be professional regardless of what you know of an attorney or his/her past dealings, etc. Be limited as to what you tell the attorney. Make sure the attorney has sent in a formal letter of representation before discussing anything with them. Having an attorney representing the insured can be helpful. The attorney knows how claims are investigated and what the policy requires of the policyholder. The attorney can assist in getting cooperation by the insured and obtaining requested documentation for the claim. Where law enforcement contacts you concerning an insured: Note: Law enforcement may be very helpful in fraud related claim investigations. They may share with us what they have been told by the insured/claimant and we can often share our information in hopes of resolving any inconsistencies. Potential approach Follow your company policy.
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