Chapter 8 - Liability Claims

Question 1

Where is a fraudulent claim likely to be staged?

Answer 1

A public place such as a mall, restaurant, store or supermarket

Question 2

What is the most common type of occupier’s liability claim?

Answer 2

Slip and fall

Question 3

What are some techniques used to create a claim situation?

Answer 3

• Carrying water bottles to squirt the floor
• Inflicting actual injury upon themselves
• Using fake blood in their nostrils
• Pulling down display items or store merchandise

Question 4

What is a common feature of fraudulent product liability claims?

Answer 4

Missing evidence or manufactured evidence

Question 5

What are some special focuses that may apply in liability accidents?

Answer 5

• Insured and the claimant are interviewed
• Independent witnesses located and interviewed
• Statements should be taken whenever possible
• Scene should be photographed and relevant measurements taken
• Local weather conditions verified for outdoor claims

Question 6

What are some questions you would ask the claimant?

Answer 6

• What was the claimant doing at the time?
• Why was the claimant there?
• Did the claimant usually take part in that activity that led them to being there?
• How does the claimant describe what happened directly after the event?
• What was it that specifically caused the claimant’s injury?
• What part of the claimant’s body was affected?
• Are the physical characteristics associated with the event precisely described by the claimant? (weather, lighting, noises and actions)

Question 7

What is a potential indicator of fraud when it comes to legal advice and lawyers?

Answer 7

The claimant may engage a lawyer immediately after the loss to avoid contact with an adjuster or investigator

Question 8

Define paralegal

Answer 8

Provides certain limited law services, is not a lawyer. Can be supervised by lawyers or unsupervised

Question 9

What are the five areas in which experts or forensic specialists may be utilized?

Answer 9

• Determine how the accident occurred
• Preserve objects related to the event
• Perform testing on objects
• Produce or analyze medical reports and other relate documentation
• Conduct surveillance and interpret results

Question 10

What must be analyzed?

Answer 10

Environmental factors, personal factors and the actual object/property directly related to the loss

Question 11

What is kinesiology?

Answer 11

The scientific study of human movement

Question 12

What are the four primary studies of kinesiology?

Answer 12

• Anatomy
• Biomechanics
• Physiology
• Psychomotor behaviour

Question 13

What other specialists may be involved in measuring, modeling and explaining physical movements?

Answer 13

Engineers, orthopedic surgeons, physical therapists, biologists, physical education professionals, mathematicians and computer experts

Question 14

Why is surveillance important in an investigation?

Answer 14

It can help to prove/disprove things, it is a deterrent, can be used for evidence and can help establish credibility

Question 15

What are some concerns that may prompt further review for doctors?

Answer 15

• Treatment is the same for various claimants for different injuries
• Boilerplate like wording
• Solo practice

Question 16

What types of injuries are common for fraud?

Answer 16

Muscle sprain, back or shoulder pain, limited movement of muscles and joints, headache, nausea, insomnia, nightmares and loss of appetite

Could be an aggravation of an old occurrence

Question 17

Define malingering

Answer 17

An intentional effort to obtain benefits by deception

Question 18

What are the four common types of diagnosis?

Answer 18

• Somatoform pain disorder
• Psychogenic pain syndrome
• Factitious illness
• Symptom magnification syndrome

Question 19

Explain somatoform pain disorder

Answer 19

Sometimes called myofascial pain syndrome or fibromyositis

Preoccupation with pain in the absence of adequate physical findings to account for pain or intensity

Psychological factors may be linked to the cause of pain

To diagnose the patient:

• Must have been preoccupied with pain for at least six months
• Not have any organic pathology or pathophysiological mechanism that accounts for the pain

There may be related pathology; but the complaint of pain/impairment is grossly in excess of what is expected from physical findings

Question 20

Explain psychogenic pain syndrome

Answer 20

Caused by emotional problems; but patients express the pain as a physical symptom

A sick role that is inappropriate/excessive thus blocking recovery and active life

By all objective standards they are physiologically normal, but they probably genuinely believe they are sick

Question 21

Explain factitious illness

Answer 21

Self-induced injury generally more psychopathology than malingering as secondary gain is less obvious or absent

Question 22

Explain symptom magnification syndrome

Answer 22

A self-destructive behaviour pattern consisting of self-reports and displays of inappropriate disability

Behaviour produced consciously or unconsciously

Reinforced by family, cultural, vocational and financial facilitators

Question 23

How would you lodge a formal complaint against a doctor you suspect is involved in fraudulent activity?

Answer 23

The college or institution maintaining them

Question 24

What three steps must be taken for physical evidence?

Answer 24

It must be observed, collected and preserved

Question 25

What types of professionals could be involved in insurance fraud? How?

Answer 25

Lawyers

• Has lawyer or firm retained similar cases?
• Working with the same people that they have for other similar cases?
• Did lawsuit get launched the same day of the accident?
• Have the lawyer and doctor previously paired up? Was extensive legal action taken?

Medical Professionals

• Are they working with a lawyer who has been involved in similar but unrelated cases?
• Are medical reports produced boilerplate or look similar to each other?
• Is this treatment prescribed the same despite injuries?
• Is the doctor a solo or group practice?

Question 26

Identify some injury claim red flags

Answer 26

• Witness is very eager to provide a statement to help the claimant
• Property damaged does not appear to be recently damaged or does not appear consistent with what was described
• Injury is difficult to measure as complaints are subjective
• Medical treatments appear excessive or inappropriate
• Out of pocket medical expenses were not incurred
• Recovery period is unusually long

Question 27

Identify some wage verification and employer red flags

Answer 27

• Named employer cannot be easily identified
• Employer’s business phone is an answering machine
• Employer is evasive or responds unsatisfactorily
• Employment record or earnings is hand written and/or has no business letterhead
• Claimant will not authorize access to employer records
• Claimant is self employed or related to employer
• Income is not consistent w/ occupation
• Wage statement appears altered
• Earnings loss indicated does not match standard of living

Question 28

Identify some claimant red flags

Answer 28

• Refuses medical attention at scene and only wants to see own doctor
• Started working shortly before the accident
• Employed in home based business
• Eager to settle quickly
• No authorization for medical/wage info
• Threatens legal action if not settled quickly
• Unusually knowledgeable of medical terminology
• Has claims history
• Engages lawyer known to handle dubious claims
• Engages lawyer same day or shortly after
• Reports conflicting versions of what happened

Question 29

Identify some lawyer red flags

Answer 29

• Repeatedly associated with dubious or questionable claimants
• Lawsuit launched same day of injury
• Lawyer and doctors paired up consistently
• Extensive legal action undertaken

Question 30

Identify some medical report red flags

Answer 30

• Medical report is boilerplate
• All reports are very similar
• Treatment for various claimants & injuries is the same