INVESTIGATIVE TIP #8
More on Evidence Documentation

In the last section we covered the use of video film in documenting the lack of injury of the applicant. Film can also be used to prove the fact that an applicant is working when he has alleged that he is unemployed.

The normal procedure to document current employment is by conducting an activities check to determine where the applicant is working, and then subpoenaing the relevant employment records.

This method works well as long as the applicant is not trying to hide his employment by means such as working for cash, or having his payroll checks made out to his wife or a relative, or using a false name and social security number. Unfortunately, this is not an uncommon situation.

When this is the case, an investigator must resort to documenting the applicant's work routine with the use of a still camera and/or video camera.

The best means of doing this is to obtain film of the applicant actually engaged in work at the job site, or traveling in and out of the workplace on a routine basis.

One of our cases called for documenting the fact that the applicant was working in a clothing factory under a false name and social security number. Subpoena of the records only gave us a personnel file on a fictitious person; there was no photograph in the file to prove it was our subject.

The investigator determined he would have to get inside the factory to obtain film evidence. He arranged a tour of the factory on a suitable pretext, and during this tour surreptitious photographs were taken of the applicant operating a weaving machine. This gave the insurance company the evidence required to stop payment on the claim.

INVESTIGATIVE TIP #9
Evidence - When Film is Not an Option

We have discussed in past sections the use of film and still photographs to document the employment activities of an applicant. But what does an Investigator do when the person is self-employed, working out of their residence, or working with no fixed schedule or routine? In situations like this the investigator must turn to other forms of evidence collection in order to document the applicant's wage-earning capacity.

The ways in which such evidence is obtained are almost as varied as the situations with which the investigator is presented. The investigator's own statement or testimony is often critical in documenting such a case. Other evidence collected can include items such as business cards, printed promotional pieces, written estimates, or even goods purchased directly from the applicant.

In one of our investigations we discovered that the subject was operating a business selling ammunition near an area in the mountains designated for target practice. The location was on a remote winding road, and could not be filmed without attracting notice. Instead, our investigators periodically dropped by and bought ammunition from the applicant, in order to document that he was operating the business on a routine basis. As a result, his claim that he was unable to earn a living was successfully challenged.

INVESTIGATIVE TIP #10
Fraudulent Claims - Identification Of

The first step in detecting a potentially fraudulent claim is to be able to recognize its indicators. DMA Investigations has two checklists of indicators we have compiled to assist claims professionals in identifying cases for further investigation (these are available upon request).

Once it is established that a claim has one or more of these indicators, further actions are taken to establish and document the true facts of the claim.

For example, one of the Referral/Solicitation Indicators is "The claimant was drawing unemployment insurance benefits prior to their claim." This indicator is frequently encountered these days due to the volume of recruitment for fraudulent claims that occurs on the unemployment lines.

We were conducting a routine activities check on a claimant who stated he was not able to work. Our investigator followed the claimant to an attorney's office and then to the local unemployment office, where he was caught in the act of recruiting potential claimants from the unemployment lines and taking them to the law office. With this information in hand, the case was prevented from going to trial.

INVESTIGATIVE TIP #11
Fraudulent Claims - Medical Reports

Medical examination and treatment of the claimant is a key area of the Workers' Compensation system that is open to abuse.

Ways in which abuse can occur include referrals being made between doctors and attorneys, examination costs being inflated with unnecessary testing, doctors or clinics exaggerating the nature or degree of injury, treatment being extended beyond the point where the patient has recovered, sign-in logs being falsified, bills being padded, and so on.

There are various means of uncovering and documenting instances of medical fraud and abuse of the system. The starting point is usually a thorough review of the medical records. This may lead to an inspection of the medical clinic concerned, or a background investigation of a doctor or facility involved.

An example of this was a case we recently referred to the Fraud Bureau. It involved a claimant who was sent to four different clinics for medical testing. The case did not appear to warrant all the testing that was done; a further analysis of the claim was in order.

A line-by-line review of the medical reports from each of the four clinics and testing centers showed that the sentence structure, wording and punctuation used in each of the reports was identical. Even though each report was printed using a different font and page format, it was obvious that the text came from a single source.

This led to a background investigation into the four clinics and testing centers, which disclosed that they were all owned by the same doctor. The information was turned over to the Fraud Bureau for further handling.