The Wicked Witch of Insurance Fraud?

Saturday, April 7, 2007 | 0

By Jim Smith Ladies of a certain age come in all varieties, as do 20-somethings and 30-somethings. The baby boom generation of ladies, like all generations of women and men alike, includes the good, the bad and the ethically challenged.

My inclination is to give little old ladies the benefit of the doubt, having had a very kindly grandmother who was good for cookies, cake and the occasional dollar bill slipped into my pocket when Mom wasn't looking. However, if grandmother is the cover and distraction used to get away with a fraudulent claim that comes my way, my fondness for my grandma isn't going to help you. If your claim is bogus, I will bust you.

The claimant in this case was a little old lady, who said she had gotten injured on the job, and had lost ALL use of her right arm. She couldn't use her hand or fingers, and couldn't even drive.

It began as a normal AOE/COE investigation. This 'sweet little old lady' could not stick with the disguise. On first contact, she became quite nasty (without provocation), refused to meet with me and immediately obtained the services of an attorney. Of course this was immediately reported to the insurance company examiner.

Not a cookies-and-milk type apparently.

During the course of taking statements, it became quite clear to me that there was something wrong with the employee's allegations. She had been a 'problem' employee, with pending discipline, and there was no report or evidence of a work related injury. Since the AOE/COE investigation indicated there was something funny about her allegations, we suggested surveillance be conducted, and this was authorized. We set up surveillance at the claimant's residence.

The holiday season was just beginning as we undertook the assignment. And our little old lady was fully into the grandmother role. She drove her vehicle, shopped, carried packages, presents and groceries. She picked up and carried small grandkids. We got film of her unscrewing the kid-proof baby bottle tops that are so challenging for most adults.

Only one problem with this heart-warming scene  she was using her right arm and hand fully and without any limitation, contrary to the assertions on her claim forms and to her doctor.

To underscore the 'knowing' element of fraud (as opposed to accidentally making a misstatement), our subject had two medical appointments during this period. She was driven to these medical appointments by another female, and arrived with her arm in a sling. At each appointment she maintained her original assertion that she was unable to use her right extremity, and had to keep it in a sling. Within 5 minutes of each medical appointment, film was obtained of our subject taking off the sling and taking over as the driver of the vehicle.

I don't like fraud or the people who commit it. It's why I am good at my job. Grandmother or gangster, executive or laborer  if you lie about injuries in order to collect insurance payments and I get the case, you will be busted. We may not always have enough for prosecution, but in this case we did. This file and evidence were forwarded to the DA and the preliminary hearing has been completed. The judge has determined that the case should go forward to a jury trial, which will commence shortly.

Jim Smith is the deputy director of DMA Investigations. DMA Investigations (http://www.dmainvest.com) is an independent investigations company with 45 offices in 15 states, specializing in investigations of possible Workers Comp fraud and abuse.

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