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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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REAL CASE STUDIES
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PROVING INSURANCE FRAUD
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A picture’s
worth a
thousand
words.
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
Read
Between
The Lines.
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REAL CASE STUDIES
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REAL CASE STUDIES
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· No paramedical examination
· Additional underwriting requirements satisfied on May 3, 2004
· Underwriter approved application: 4:48 p.m. on May 5, 2004
· Pronounced dead at 6:20 a.m. on May 6, 2004
· Agent was told Stacey died of a heart attack
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
· Stacey had “never been ill and didn’t have a family physician.”
· Stacey had gone to Houston to visit their mom and became ill.
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REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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REAL CASE STUDIES
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REAL CASE STUDIES
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· Told the agent in January 2004 that Stacey was mentally ill
and living in a nursing home.
· One friend went with her and Stacey to the agent’s office to
sign the application on March 17, 2004.
· “no questions were asked.”
· she and Stacey “both signed paperwork” where told.
· Is “sure the agent is trying to trick her as she is sure the agent
forged her signature on the policy.”
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
Dig deep . . .
really deep.
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
Autopsy Report
Death was the result of “[c]ardiomegaly associated with
hypertensive cardiovascular disease,” secondary to
obesity.
Height: 5’ 4”
Weight: 309 lbs.
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
Medical Records
· hypertension, with non-compliance regarding
treatment and abnormal EKG’s associated with the
hypertension;
· asthma, COPD and pulmonary hypertension;
· obesity;
· congestive heart failure and cardiomegaly; and
· ten year history of mental/nervous disorders, including
numerous medications and institutional stays.
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REAL CASE STUDIES
Medical Records
(California) Medical Center 6/17/2003 - 10/31/2003
(California) Care Center 10/31/2003 - 1/23/2004
(California) Hospital 1/23/2004 - 1/27/2004
(California) Nursing Home 1/27/2004 - 3/5/2004
(California) Hospital 3/5/2004 - 3/11/2004
(Texas) Hospital 3/14/2004 - 4/8/2004*
(Texas) Hospital E.R. 4/11/2004 - 4/12/2004
(Texas) Psych Ward 4/12/2004 - 5/6/2004
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REAL CASE STUDIES
Medical Records
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REAL CASE STUDIES
Get them
to commit.
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REAL CASE STUDIES
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REAL CASE STUDIES
Tie up any
loose ends.
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REAL CASE STUDIES
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PROVING INSURANCE FRAUD
REAL CASE STUDIES
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REAL CASE STUDIES
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Get an
Explanation.
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REAL CASE STUDIES
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REAL CASE STUDIES
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Insurance Laws
California “If a representation is false in a material point,
whether affirmative or promissory, the injured
party is entitled to rescind the contract from the
time the representation becomes false.”
Cal. Ins. Code §359
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Insurance Laws
No. Carolina “. . . a representation, unless material or
fraudulent, will not prevent a recovery on the
policy.”
N.C. Gen. Stat. §58-3-10
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REAL CASE STUDIES
Insurance Laws
Ohio No answer to any interrogatory made by an applicant in
his application for a policy shall bar the right to recover
upon any policy issued thereon . . . unless it is clearly
proved that such answer is willfully false, that it was
fraudulently made, that it is material, and that it induced
the company to issue the policy, that but for such
answer the policy would not have been issued, and
that the agent or company had no knowledge of the
falsity or fraud of such answer.
Ohio Rev. Code §3911.06
See also, Ohio Rev. Code §3923.14
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Consider Alternatives
Application Agreement:
“Coverage will be effective as of the policy date if the
following conditions are met:
· the first premium is paid when the policy is
delivered;
· the Proposed Insureds are living on the
delivery date; and
· on the delivery date, the information given to
the Company is true and complete without
material changes.
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Consider Alternatives
Binding Receipt:
· “There is no coverage under this Receipt if the
application contains any material misrepresentation.”
· “No death benefit is provided by this Receipt unless
death results from an accident that occurs or an
illness that first manifests itself after the Application
Date.”
· “Coverage under this Receipt will end when the first of the
following occurs: (a) The application is approved; (b) Notice
of disapproval of the application is given; (c) 60 days have
expired starting with the Application Date.”
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Gather all
your bricks.
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Rescission Checklist
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Rescission Checklist
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Rescission Checklist
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Rescission Checklist
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Rescission Checklist
4. Misrepresentation/Concealment
· Are there misrepresentations in the application?
· Were facts omitted from responses in the application?
· Were the facts subjective or objective?
“Have you ever received treatment for or been
diagnosed as having or had any of the following?”
“Within the past 5 years have you had a physical
examination, medical consultation, X-ray or
laboratory study, or been a patient in a hospital
or other medical facility?”
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REAL CASE STUDIES
Rescission Checklist
5. Materiality
· Were the misrepresented/concealed facts material?
· Is there an underwriter’s opinion about materiality?
· Are there written underwriting guidelines that support the
underwriter’s opinion?
· Did the underwriter comply with those guidelines?
· What information did the underwriter consider?
· Did the underwriter know of other facts that created a
duty to make further inquiries?
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Rescission Checklist
6. Conditional Receipts
· Generally two types that provide different contractual
rights:
1) Provides coverage if conditions are met, with a
beginning and end date;
2) Fixes a date for determining insurability, if
conditions are met.
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Rescission Checklist
6. Conditional Receipts
· When did the Company get the money?
· How long did it take to underwrite the application?
· Compare to company standards
· What caused the delay?
· Was the policy delivered?
· How?
· By whom?
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Rescission Checklist
7. Change in Health
· What documents were signed at time of delivery?
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Rescission Checklist
8. Reinstated Policies
· Was the policy ever reinstated?
· Does the reinstatement application provide an
alternative basis for adjudicating the claim?
“The reinstated policy will only cover disabilities
due to injury occurring after the date of
reinstatement, and due to sickness beginning
more than 10 days after that date.”
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Rescission Checklist
9. Agent Misconduct
· Investigate the agent’s relationship with the company
and with the insured
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Rescission Checklist
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Leave no stone
unturned.
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Shop around.
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Cynthia: Went to agent’s while shopping since just got tax refund
Agent: No way (and no reason) to post-date binding receipt
Binding Receipt: No coverage 60 days after application date
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Agent had never met, talked to, or talked with anyone about Stacey,
but application had her:
· Address · Date of Birth · Social Security Number
Agent had never met, talked to, or talked with anyone about Cynthia’s
kids, but:
· all 3 are named in application
· all 3 have a different last name than Cynthia
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Keep the
stories
straight.
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Underwriter’s Perspective
· 32 year old non-smoker
· 5’1” and 120 lbs.
· No adverse medical/psychiatric history
Claim Handlers’ Perspective
· 32 year old smoker
· “about” 260 lbs.
· Significant undisclosed medical/psychiatric history
· Imposter at point of sale
Jury’s Perspective
· 309 lbs.
· Cynthia and her mother were told she was dying
· Could not have been in agent’s office on either date
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Remember the
“simple” truth.
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QUESTIONS?
Robert R. Pohls, Managing Attorney
e-mail: rpohls@califehealth.com