True Crime of Insurance Fraud Video Number 44

Barry Zalma, Esq., CFE presents videos so you can learn how insurance fraud is perpetrated and what is necessary to deter or defeat insurance fraud. This Video Blog of True Crime Stories of Insurance Fraud with the names and places changed to protect the guilty are all based upon investigations conducted by me and fictionalized to create a learning environment for claims personnel, SIU investigators, insurers, police, and lawyers better understand insurance fraud and weapons that can be used to deter or defeat a fraudulent insurance claim.

Insurance Premium Fraud

Insurance fraud is not limited to fake claims. Most people don’t present claims. The basic principle upon which insurance is based require the many to pay small amounts so that the few can collect. If the risk is not spread fairly among the many, all suffer.

Most businessmen would be shocked at a suggestion that they inflate a claim. They are honest in their business dealings. They honor their contracts and pay their bills. They seldom have insurance claims. When they have a claim, they deal fairly and honorably with their insurer.

Paying insurance premiums hurt. The marketplace is competitive. Prices vary from insurer to insurer. Skills vary from insurance broker to insurance broker.

Eventually, businessmen learn how insurers set their premiums. They know that rates are applied to modifiers like the square footage of the structure, the payroll, or the gross receipts of the business.

A businessman, sitting with his insurance broker, asks how he can get the lowest premium. He will often put his morality on hold when the broker suggests that he estimate a lower amount of gross earnings. The businessman will see nothing wrong with loping 10,000 square feet of his 50,000-square foot warehouse when applying for insurance. When called upon to list the payroll for his workers’ compensation policy, he will be unconcerned when he tells his broker the payroll is $200,000 less than it actually is. It is just good business sense to reduce your workers’ compensation premium. When his policy shows factory workers cost more to insure than clerical, he “accidentally” reports to his workers’ compensation insurer that ten percent of his employees are factory workers and ninety percent are clerical, although the opposite is true.

What the businessman does not know, and what his broker does not tell him, is that knowingly misrepresenting a material fact [and there is nothing more material to an insurer than the basis upon which the premiums are calculated] is fraud. Insurance fraud in the acquisition of insurance bears both civil and criminal penalties.

An insurance broker who aids or abets and insured in obtaining lower premiums based upon false information is equally guilty of fraud. The agent or broker who does not require the insured to sign an application will find, if the fraud is discovered, that the insured will deny knowledge of the application. He will merely say, “I trusted my broker. My records were obvious in my office. All he had to do was ask and I would have told him the truth.”

The broker, faced with such a situation, will find himself defending lawsuits brought by the insured and the insurer.

The California Insurance Code now requires the following warning on all claims documents presented to insureds by insurers:

FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM

ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.

I believe, to protect the insured, the broker and the insurer, that the law should be modified to require the same warning on every application for insurance. A warning will not stop a person intent on committing fraud. It will, however, remind the honest businessman tempted to commit fraud to obtain a lower premium of the hazards of his actions.

Insurance fraud is not limited to fake claims. Most people don’t present claims. The basic principle upon which insurance is based require the many to pay small amounts so that the few can collect. If the risk is not spread fairly among the many, all suffer.

What the businessman does not know, and what his broker does not tell him, is that knowingly misrepresenting a material fact [and there is nothing more material to an insurer than the basis upon which the premiums are calculated] is fraud. Insurance fraud in the acquisition of insurance bears both civil and criminal penalties.

Every claim adjuster and investigator should review every word on the application and obtain the insured’s answers asked as if the adjuster has no knowledge of the answers on the application form or be criticized for not completing a thorough investigation.

(c) 2022 Barry Zalma & ClaimSchool, Inc.

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