CLAIMS INVESTIGATION TOOLS AND BEST PRACTICES. Dan Sibley Field Investigator Pool Claims (615)

Transcription

1 CLAIMS INVESTIGATION TOOLS AND BEST PRACTICES Dan Sibley Field Investigator Pool Claims (615)

2 PURPOSE OF A GOOD INVESTIGATION Workers Compensation To establish compensability - did injury occur in the course and scope of employment To establish causation - does the reported injury meet the 50% threshold Rule out fraud Identify opportunities for recovery (subrogation) Loss control

3 PURPOSE OF A GOOD INVESTIGATION Liability Includes General Liability, Auto Liability, Law Enforcement Liability, Employment Practices Liability, Employment Benefits Liability, Errors and Omissions and Liability Arising from Cyber and Privacy issues - Helps prove what you already know. You have to remember that what you know cannot always be proven at trial. - If it is determined early on that exposure exists, action can be taken early on to resolve. - Early investigations preserve evidence when it is fresh in everyone s minds - New defense opportunities identified

4 INVESTIGATIVE TOOLS - Recorded Statements of Involved Parties - Preservation of Contracts and other Documentation - Independent Investigators/Adjusters - Surveillance - Web Crawls on Social Media - Medical Records/Gym/Golf Canvass - Skip Trace - Witness Canvass - Experts/Engineers - Activity Checks - Scene Investigations - Accident Reconstruction - Vehicle Tag Sightings - Employment Searches - Civil/Criminal Searches and Index Bureau

5 CASE STUDY 1 Facts: Single, middle aged female claims total disability due to a back injury suffered when a fire truck pulled the front bumper off of her vehicle. Claimant was alleging that she could not work and was in constant pain. She was very uncooperative when providing medical information. Tools Used: Medical Canvass: Located significant medical history of back issues that pre-dated the accident by many years. We were able to subpoena these records. Web Crawl: Located a multi-level marketing blog where the plaintiff was selling oils. She claimed that she was 100% healed with no pain. Employment Search: Found that she was working at a health spa Surveillance: Three days of video through front of spa. Walking, lifting chairs and answering phones with no discomfort Results: Cost of defense settlement made

6 CASE STUDY 2 Facts: Two teenagers witnessed an altercation in a parking lot that resulted in an arrest. The arrest and further prosecution of an individual were challenged. We needed to locate the two individuals but all we had was a still security video. Video was over a year old. Tools Used: - Good ole nose to the grindstone field work : Investigator realized that the subjects were teenagers so he visited with the high school SRO. He identified the two subjects. - Skip Trace: Located various addresses and physically visited those addresses. Subjects did not live there but someone knew them. Advised that they had moved out of State. - Skip Trace Again: Located subjects living in a trailer park in Florida - Independent Investigator: Took statement of the witnesses in Florida Results: Lost at trial. Appealed and prevailed on appeal.

7 CASE STUDY 3 Facts: Questionable auto accident involving an intersection. Clmt alleged that the insured failed to yield and she was alleging severe injuries. Clmt was a teenager with her Father supporting her in her claim. Tools Used: - Web Crawl: Located Instagram and Facebook account of claimant telling everyone that she was going to get rich off this. Continued to brag about how she was going to take advantage of the situation. - Field Investigation: Sent investigator to her home and took recorded statement that contradicted her social media rants. Results: Tried the case when liability was questionable. The Judge was not impressed with her credibility when shown the evidence collected. Defense Verdict