DMAClaims.com Fraud Chronicles 10: Diagnosis – Fraud
By Tom Reitze
Occasionally a person gets traumatized in the workplace, and a psychiatrist can't figure out what's wrong with them. But sometimes, it's so simple that it eludes the "professional" with the supposedly advanced degrees, but is plain as day to someone else: they're just faking it.
In a case where the insurance company suspects that a person might be faking their disability, an investigator is often brought in to find out the real facts. DMA Claims Services (http://www.dmaclaims.com) investigates suspicious cases, conducts surveillance, and if a person is found to be engaged in activity inconsistent with their claim, films the subject in the act. Then that evidence is turned over to the insurance company.
This is a case from the DMA Claims Services Investigations archives, Part 10 of the Fraud Chronicles, where the psychiatrist couldn't figure out the claimant's real ailment, but it was as clear as day to the insurance examiner.
Diagnosis – Fraud
This claim was based on a supposed workplace incident and trauma so severe that our traumatized claimant could not work at all, and filed for financial relief courtesy of the Worker's Compensation carrier. According to her claim the incident had caused her to not be able to leave her house or speak to anyone outside her immediate family.
She began treating with a psychiatrist as well. As the weeks rolled by, she showed no improvement. Coincidentally, the insurance examiner on the claim was among the people she could not speak to, and the claimant's mother had to act as her representative.
The psychiatrist continued to treat the claimant with no result and no idea of what might be wrong with her that might be cured. The insurance examiner on the other hand (without needing an advanced psychiatric degree) diagnosed the case perfectly. Her prescription? Put the claimant under surveillance.
The insurance examiner assigned the case to DMA Claims Services. Before long, our investigator had ample videotape of this claimant, who supposedly could not leave her house or talk to anyone outside of her family, working at a hair salon on a regular basis. The video showed her laughing and chatting with customers while she did their hair. The examiner's diagnosis had been correct. A severe case of insurance fraud.
The insurance carrier decided to pursue criminal prosecution of this claimant. To get further evidence, one of our investigators showed up unannounced at the hair salon and found her there, working. He got a statement from her in which she lied repeatedly, about when she started working, her work schedule and about other activities we had filmed and documented during our investigation.
Our Special Investigations Unit packaged up the evidence and sent it to the authorities. We have recently learned that the examiner's diagnosis, combined with our investigator's effective treatment, resulted in a full cure of our "traumatized" claimant's ailment. She was arrested for insurance fraud.
About the Author
Tom Reitze is President of DMA Claims Services (http://www.dmaclaims.com) , an independent investigations and claims adjusting company with 45 offices in 15 states.
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