INSURANCE FRAUD: What Happens When Reported to the OIC? May 21st, 2013

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1 OFFICE OF THE INSURANCE COMMISSIONER SPECIAL INVESTIGATIONS UNIT INSURANCE FRAUD: What Happens When Reported to the OIC? May 21st, 2013

2 FRAUD IS A CRIME (THEFT!) 75 months for woman who bilked elderly clients - Local & Regional - Seattle News.wmv

3 Speaker Bio: OSP WSP OIC

4 INSURANCE FRAUD = VICTIMS POLICY HOLDERS INSURANCE COMPANIES YOU INDIRECTLY OR DIRECTLY..?

5 INSURANCE FRAUD COSTS US ALL Conservative estimate: 10% of claims are fraudulent = $1.67 billion in WA* $250 for every man, woman, and child in WA $625 per household in WA *FBI.gov; III.org; NICB.org; Insuranceshopperpa.com; Insurancefraud.org; 4/21/2010

6 OFFICE OF THE INSURANCE COMMISSIONER Independently elected Commissioner Regulates the insurance industry Provides consumer protection and assistance Funded by fees from insurance carriers Investigates fraud for criminal prosecution

7 OIC-SPECIAL INVESTIGATIONS UNIT Peace officer status Conducts criminal fraud investigations Serves search warrants Submits cases to prosecutor Arrests subjects

8 How We Receive Referrals Insurance Companies National Insurance Crime Bureau Office of Insurance Commissioner Staff Law Enforcement The Public Website:

9 Referrals What Happens? SCaMS (SIU Case Management System) Analyst Review Staff Review Prosecutor Review Decision Point: Open a Criminal Case

10 Some State Laws: RCW Insurance Fraud Defined knowingly, and with intent to defraud, commits, or conceals any material information RCW Disclosing Insurance Fraud (1) Any insurer or licensee of the commissioner that has reasonable belief that an act of insurance fraud which is or may be a crime under WA law has been, is being, or is about to be committed shall furnish and disclose the knowledge and information to the commissioner or the NICB, NAIC,

11 Some State Laws: RCW (continued) (2) Any person that has a reasonable belief that an act of insurance fraud which is or may be a crime under WA law has been, is being, or is about to be committed; or any person who collects, reviews, or analyzes information concerning insurance fraud which is or may be a crime under WA law may furnish and disclose any information concerning such an act to the commissioner or to an authorized representative of an insurer that requests the information for the purpose of detecting, prosecuting, or preventing insurance fraud.

12 When to call? Insurance Company is the victim Personal knowledge Something seems wrong Documents or numbers don t add up Inconsistent statements

13 Active Cases OIC - SIU Cases by Type 4% 4% Bodily Injury Disability 14% 11% 11% 14% Medical Provider Personal Property/Property Damage Producer Fraud Service Provider Fraud 43% Staged Auto Collision 9/30/12 OIC SPECIAL INVESTIGATIONS UNIT

14 Key Performance Measure - OFM Restitution, Immediate & Projected Loss Prevented ( Biennium) 1 st Qtr 2 nd Qtr 3 rd Qtr 4 th Qtr 5 th Qtr Bien to Date Estimate $ 400,000 $ 700,000 $ 200,000 $ 150,000 $ 100,000 $ 1,550,000 Actual $1,623,715 $ 253,496 $ 172,216 $9,821,384 $1,918,816 $13,789,627 Variance $1,223,715 ($ 446,504) ($ 27,784) $9,671,384 $1,818,816 $12,239,627

15 SIU stays busy For ,144 Referrals reviewed 64 Criminal Cases opened $11,995,121 Restitution and Immediate & Projected Loss prevented (CY 2012)

16 Where our cases have been OIC SPECIAL INVESTIGATIONS UNIT

17 People love pets even fake ones

18 Cases in the Media...

19 Media attention included MSN Money, CNBC, NPR, as well as media in California, Oregon, Idaho, Arizona, Illinois, Alaska, Missouri and even Russia. ONE THAT WENT GLOBAL

20 The Material Girl - Overview Licensed Producer Account Manager -Banker s Life Insurance Stole $1,052,088 ( ) 5 victims identified ages Spent money very lavishly

21 The Material Girl - Epilogue Plead Guilty (2x) to 10 counts of 1 st degree Theft Sentenced to 6 years, 3 months in prison $859,929 Restitution ordered Jasmine Jamrus-Kassim

22 The Surgeon - Overview Licensed Technician Sole Proprietor Alpine Surgical Services Billed Insurance Companies and their Customers as either a Physician s Assistant or Surgeon Billed for surgeries that never occurred Total Billings: $ 7,441,500 ( )

23 The Surgeon - Epilogue Plead Guilty to 7 counts of Theft Sentenced to 1 year in jail $ 472,458 ordered restitution Kenneth Welling

24 The work behind the scenes

25 PART OF JUST ONE CASE

26 Search Warrants

27 REACTIONS BY SUSPECTS VARY

28 The Business Agent - Overview Licensed Producer Nancy Bishop Agency Selling liability coverage for small businesses Accepted Payments Produced certificates of coverage

29 A real quote

30 A real statement

31 But A fake certificate

32 The Business Agent - Epilogue Plead Guilty to 1 st Degree Theft and Forgery 3 months Jail; 3 months electronic home monitoring Nancy Bishop $71, 600 fines/restitution

33 POLICE RESOURCES WASTED

34 The Bike Thief Overview False Claim for $18K stolen bicycles Filed false police report Submitted forged documents Impersonating officer (via )

35 The Bike Thief - Epilogue Skipped arraignment Warrant issued Posted frequently on facebook Arrested at fitness club Pled Guilty 2 counts of Forgery 45 days, $800 fine John Southerly

36 Social Media

37 Social Media

38 Some helpful OIC resources:

39 SUMMARY: Insurance companies are required by law to report fraud to OIC SIU works criminal cases Our focus is organized and/or large schemes

40 Thank you Questions and comments? Visit us at:

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