09/25/2008 03:04:28 PM EST
It is Necessary to Know Insurance to Fight Insurance Fraud
According to the Coalition Against Insurance Fraud: “When it comes to insurance fraud, the United States is a world leader. We arguably have the most severe problem on the planet. But we also have the most sophisticated means of combatting fraud. Our systems for detecting and investigating fraud are mature and much more robust than those in other developed nations.”
Although I agree with the Coalition that the ability to detect and investigate fraud is as useful as an arrest without a conviction. Detecting and investigating fraud is merely the beginning of the process. If the fraud investigators are not sufficiently trained about insurance, insurance contract interpretation, and civil defenses to attempts at insurance fraud it does not matter how robust and mature the ability to investigate and detect fraud. The mature and robust talents must be joined with civil defenses to fraud and the criminal prosecution of the perpetrators.
Insurance fraud is a multi-billion dollar, complex, multi-faceted problem.Those charged with investigating and detecting insurance fraud must institute a serious and detailed training program for its fraud investigators to make them knowledgeable, at the very least, about:
- How to read and interpret an insurance policy
- How to enforce the material conditions in a policy of insurance.
- How to enforce the warranties in an insurance policy.
- The effect of a material misrepresentation or concealment of a material fact at the time a policy is acquired.
- The crime of insurance fraud and the evidence necessary to prove the crime.
- How “red flags” of insurance fraud lead to evidence but are not evidence of fraud. Insurance fraud is a multi-billion dollar, complex, multi-faceted problem.
If insurers refuse to train their people they will continue to detect fraud, investigate it thoroughly, and then pay the perpetrator because they failed to prove a viable defense to the fraud.