Catching Insurance Frauds

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Who would ever tell their Junior High School Guidance Counselor that they wanted to be an insurance claims examiner when they grew up? I certainly never said that was what I wanted to be…but there I was…a young man in a 5-year training program, employed by a very large insurance company. I was fortunate that my employer was a mutual insurance company and not a stock company. You see, a mutual company is owned by the policyholders and consequently, any profits made go back to those policyholders and the company is answerable to the insured owners. Conversely, stock companies are owned by stockholders and are motivated toward quarterly profits for their shareholders. Needless to say, stock companies take greater risks than mutual companies.

My Resume'

I had marvelous mentors. One man, in particular, was 40 years my senior and yet he exhibited patience with me, shared a lifetime of knowledge (both business and personal) and introduced me into the detailed world of a claims examiner. I was excited, overwhelmed and intrigued by my new duties that I had accidentally fallen into and ended up loving. Yes, you read that correctly…I loved what I did for a living. I excelled at my job, first as a Disability Claims Examiner, then a Disability Income Specialist, I moved on to a Claims Manager and eventually I became a Benefits Administrator. I handled disability income, suicide, homicide and accidental death claims, along with preparing compromise settlements with attorneys and claimants. I prepared lawsuit referrals for our legal department attorneys and answered detailed State Insurance Department inquiries. I had a natural nose for this business which would become a game of wits. Not to be lost in my quest to be the best in my field, was my personal mission statement to make sure all legitimate claims were paid and to deny those that did not fall under the terms of a contract or were clearly cases of fraud.

DOUBLE INDEMNITY

Most life insurance policies have a “Suicide Clause” that generally excludes payment of death benefits proceeds if the insured commits suicide within the first 2 years, from the date of issue to date of death. The premise behind a suicide clause is that most people don’t purchase life insurance with the intent of committing suicide 2 years and 1 day after a policy is issued. DOUBLE INDEMNITY is the doubling of a policy’s face value in the event death has been the direct result of accidental means. Naturally, before a company pays a double indemnity, they will do an exhaustive investigation to make sure an insured’s death was in fact, due to accidental means.

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A MEAT MALLET, MERCEDES BENZ AND A REAL CLIFFHANGER

The police determined that after the doctor assaulted his wife with a meat mallet, he drove from the scene of the crime when his Mercedes-Benz went off the side of the road and landed upright on a boulder. The report went on to state that upon impact, the doctor’s neck got caught in the seat belt as he was hurled through the passenger window and found hanging on the outside of his car. My mentor had a rather large magnifying glass when he called me over to his desk. “Dennis, what do you see in this picture?” he asked. Showing my naivete, I quickly replied that I saw a body, hanging out of a car window, dangling over a cliff. Calmly, the elder examiner told me to look at the deceased’s neck, using the magnifying glass. That’s when he pointed out the seat belt was actually wrapped around the deceased’s neck twice. After numerous tests, it was determined to be physically impossible for a body to accidentally have a seat belt go around the neck twice, while being flung from the driver's seat, across the passenger's side of the vehicle and through the passenger's window. Subsequently, the original police report was overturned and the cause of death was changed from accident to suicide and only the face amount of life insurance was paid.

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COMMIT A CRIME AND YOU WON’T COLLECT A DIME

In its simplest form, Disability Income Insurance will pay a stipulated benefit to a policyholder who becomes disabled due to sickness or accident within the terms and conditions of their policy.

The claimant seemed to have a valid claim to receive disability income benefits after losing three fingers in a boating accident explosion. However, things aren’t always what they appear to be. Doctor and hospital records proved there was trauma with the loss of fingers and yes, the accident did occur during a boat explosion. What the insured had failed to report were his criminal activities. For you see, in checking newspaper clippings, interviewing people and inquiring with other insurance companies, our claimant was linked to a history of sinking, setting fires and blowing up boats along the Mississippi River so that boat owners could collect insurance on their luxury crafts. Apparently, our guy, obviously no rocket scientist, was nothing more than a hired thug. He not only had his disability income declined, but he didn’t need any money anyway because he was sent up the river to the “Big House.”

Source

BACK ON THE ROAD TO CAMPING


Things aren't always what they appear to be as evidenced by an insured complaining he had injured his back. I wanted to place him under surveillance even though the investigator contacted me after a one on one interview and explained how the claimant literally had tears running down his cheeks while attempting to lift his coffee cup. I was still skeptical when I instructed him to place a surveillance at both ends of the insured's residential street. Within a couple of hours, my telephone rang again and mysteriously the investigator was laughing. It appears my hunch was correct as pointed out by video evidence of the claimant walking out of his front door and up to the back of his camper, where he proceeded to use both hands attempting to jockey it into place on the back of his pickup truck.This guy could have won an Academy Award for having crocodile tears one moment and then acting like Joe Atlas the next moment.

HELLO…IS THIS THE PARTY TO WHOM I’M SPEAKING

He was a bar and restaurant owner in California who had collected disability benefits for several months. I knew he was working and yet I couldn’t prove it. Every time I called the insured or sent an investigator to his establishment he claimed he had just stopped in to pick up his mail. The three hour time difference was proving to be an obstacle. This was back in the days of outrageously high long distance phone charges. My intuition got the best of me and I asked my boss if I could make a long distance call from home and charge it to the company and he agreed. When my alarm went off at 3:00 on a Saturday morning, I tiptoed downstairs, closed the family room door and called Bill (not his real name) at the bar and restaurant. An employee answered the phone with the background noise of music and a loud boisterous crowd. I yelled into the phone, “Hi is Bill tending bar tonight?” “Yes, he is,” was the answer. “May I speak with him,” I asked? “We’re really busy tonight. Can I tell Bill who is calling” the worker inquired? “Well, I’m an old friend from back east and I really want to surprise him,” I replied. The ensuing conversation went something like this: “Bill you’ve got a call? Who is it because I’m swamped? I don’t know. It’s some guy who says he’s a friend from back east and wants to talk to you. Okay, give me the phone. Hey Bill…working your tail off tonight aren’t you? Oh, you know it. We’re buried. Wait a second, who is this? I’m so glad to hear you’re back to work because this is Dennis Page with Mutual of XYZ and on Monday I’ll send you your final check through Friday. You got me. That will be fine. Thank you.” I felt like George Peppard in the “A-Team when at the end of the show he would proclaim, “I love it when a plan comes together.”

EVERY WORD OUT OF YOUR MOUTH MAKES ME SICK

He was a German tennis professional who claimed he was so disabled he couldn’t even hold a tennis racket. The wonders of video proved otherwise when we had taped evidence of the insured giving private tennis lessons. When I terminated benefits I received a phone call and in broken English I was told in no uncertain terms the following: “Mr. Page, every word out of your mouth makes me sick.”

$20.00 IN CAB FARE – NOW GET OUT OF MY OFFICE

Carl (not his real name) was a large and imposing man who had received monthly disability payments for several months due to neck and back pain. It was time for me to send him for an independent medical examination by a Board Certified Orthopedic Surgeon. The doctor’s testing indicated the patient had a limited range of motion with his neck, arms, and back, exhibiting immense pain during his 30-minute office visit. The report I received was worded something like this:

Upon completion, I instructed the patient he could now get dressed, at which point he leaned forward to slip on his undershirt, pulled it over his head and raised both arms in the air without visible signs of distress or range of motion. He then proceeded to sit down, bent over and put on both socks without difficulty. The patient was able to balance on one leg while he slipped on his pants and did so with ease. He again sat down, slipped his feet into his shoes, bent over and tied both shoes with fine finger dexterity and no outward signs of discomfort. Finally, the patient moved his right arm in the direction of his back, bending it at the elbow and placed his arm in his jacket. The patient repeated the same range of motion in his left arm, again without outward signs of pain or restricted movement.

After I had denied Carl’s claim, I received a call from the emotionally upset orthopedic surgeon. His voice was quivering. Apparently Carl had showed up at the doctor’s office, challenging and intimidating both the physician and his staff until the doctor gave him $20.00 in cab fare just so he would leave. I can’t even begin to tell you all of the expletive words Carl threw my way, but with any business, you learn to take the bad with the good.





I remember when we started receiving our first autoimmune deficiency (AIDS) cases in 1982. There wasn’t a whole lot of data about the AIDS virus back then. I was shocked when I opened the police envelope and saw pictures of a naked man hanging in a doorway, with pornographic photos strewn across the floor. In those days, that type of death was referred to as sexual asphyxiation. Eventually, the term was upgraded to “auto-erotica.” The first decomposed body of a suicide I saw was that of a man who had asphyxiated himself in his car and his body wasn’t discovered for months. The only image that stuck in my mind from all of the photographs was burnt chicken. Needless to say, when I got home from work that same evening my wife had prepared to perfection, two Rock Cornish game hens. I didn’t eat dinner that night.

Frauds and liars have been around since the beginning of time. Thankfully the world is full of more honest people than dishonest ones. I was proud of the job I did. I was a salaried employee who took work home most nights and weekends. The diversity of my cases kept me interested and enthralled and all these years later I still miss what I did to earn a living. There are not too many people who can make that statement.

WRITTEN BY: DENNIS L. PAGE

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Comments 18 comments

hawaiianodysseus profile image

hawaiianodysseus 3 years ago from Southeast Washington state

Dennis, I applaud you (after I'm done laughing, that is!) for sharing vignettes from your former life as an insurance claims examiner. An entire television series could be built around this premise.

I'm still reeling from the image of burnt chicken. Ha-ha!

Dennis. you are something else! And that's why I love your writing! It is unique, fresh, and definitely YOU!

Aloha, my friend! Have a great weekend!

Joe


billybuc profile image

billybuc 3 years ago from Olympia, WA

Dennis, that was the most entertaining hub I have read today...by far. Thanks for sharing some of your experiences. I fear I do not have the temperament to do that job. :)

Have a great weekend.

bill


Deborah Brooks profile image

Deborah Brooks 3 years ago from Brownsville,TX

Dennis...what a great hub...it looks like. You really.liked your

Job and was really good at your job. The stories of the different

People that ripped off

The system. So good..

Blessings

Deb


ImKarn23 profile image

ImKarn23 3 years ago

OMG, D - being a mere disability insurance AGENT for 14 years - i absolutely HOWLED at your stories! I could add a few AND a few more about being chased around tables till i could get to the door - etc...

It's hard for me to wrap my head around what you did for a living - what with all the surveillance and distrust...lol..

i couldn't pick a fav but i LOVED the guy who blew his fingers off AND the idiot who bent over to tie his shoelaces..

LOL..

voting/sharing, my friend..

HEY - wasn't this on my fb page when i went to sleep last night? where'd it go?


shiningirisheyes profile image

shiningirisheyes 3 years ago from Upstate, New York

Excellent hub that I found truly fascinating. I am always astounded at the criminal means some will go to.

What an interesting field of work.


pagesvoice profile image

pagesvoice 3 years ago from New York/Pennsylvania border Author

@ hawaiianodysseus - It is always such a pleasant surprise to have you read and comment on my articles. I really did handle some strange cases throughout the years. However, those cases are the ones that kept my job so interesting and challenging.


pagesvoice profile image

pagesvoice 3 years ago from New York/Pennsylvania border Author

@ billybuc - Thank you for peeking into a part of my life. I'm thrilled you found my hub to be entertaining. There were some days I would leave the office smiling ear to ear and then there were those sad days where a personal tragedy just struck a nerve. It all balanced out.


pagesvoice profile image

pagesvoice 3 years ago from New York/Pennsylvania border Author

@ Debroh Brooks - I was so glad to see that you popped in and read my little story.

One thing I learned in my career is the fact that some people play by the rules and others do not and that is when the game of wits would begin.


pagesvoice profile image

pagesvoice 3 years ago from New York/Pennsylvania border Author

@ ImKarn23 - You never disappoint me with your remarks.

So you sold insurance, eh? I was licensed to sell life, accident an health insurance in New York, Pennsylvania and Florida. I also sold group insurance policies. I then obtained a property and casualty license and eventually became a New York State licensed General Insurance Consultant. Oh Ms. L., do you remember those early days of making 100 telephone calls per day? Weren't they fun?


pagesvoice profile image

pagesvoice 3 years ago from New York/Pennsylvania border Author

@shiningirisheyes - I'm so happy you stopped by and enjoyed this somewhat entertaining hub. The dishonest end up costing the above board people more in premiums and a slew of other goods in an effort to cover their losses.


tillsontitan profile image

tillsontitan 3 years ago from New York

Now I dear pagesvoice was on the other side of the same spectrum...I worked for an attorney who practicesed in every area but specialized in no-fault (automobile) cases. I truly know from whence you speak and enjoyed this hub tremendously!

Now, we need to clone you about a couple of thousand times and send you out to work for the Government in the Welfare Fraud Department!!

Really enjoyed this though and hope you have more stories up your sleeve.

Voted up, awesome, interesting and shared with my readers.


tsmog profile image

tsmog 3 years ago from Escondido, CA

Interesting perspectives of learning shared. I can appreciate such and such with internal corporate this and that's. I think it may have been when younger managing a tire store I first head tales of that.

Seems those national accounts like the DEA and being local of San Diego those from the Navy did drink a beer or two now and then. I would sit there in awe with stories just like those shared here. I appreciate the efforts of investigations too.

A friend of a local lockup for evidence says each piece he cares for has a story. His wife being the first hired woman of that force now retired leaving behind investigations of spousal abuse and child stuff left some scars. Some times those Bar-B-ques offer no tales, seems more therapeutic knowing of the power of real friendships of many years.

I tip my hat knowing you paid your dues. Most assuredly when in Junior High School I pondered architecture and now I pound a keyboard pretty much when ever I can. I can relate to what you have shared here with how life changes. I admire you for sharing insight of what many only know from TV. You lived it. Both respect is offered and sharing I look forward to more coming across the home feed.

Mitch


Cantuhearmescream profile image

Cantuhearmescream 3 years ago from New York

pagesvoice,

I don't think you understand how much I appreciate this hub. I belong to a fire department, which I am a Captain and have been there for almost 15 years. We reside inside of a small village and we are one of the only departments or villages around to still host field days, as our biggest form of fundraising. Five years ago, we had an out of shape, female firefighter, leave her 'post' and tried intervening in an altercation. She was consequently knocked down and claimed to have 'hurt' her ankle. She did go see a doctor and it hadn't amounted to an awful lot, beside maybe a brace for a few weeks. When 'returning' to the fire company, after her 'injury', our Chief required a medical release from her doctor, stating that she was in good health and able to participate again. The doctor cleared her from any/all medical issues and noted her only health issue was obesity. A year later, a lawsuit showed up on the doorstep of our village (of less than 300 residents). We are to a point of owing her more than $400,000 because Compensation is generous to firefighters, despite the fact she was unemployed at the time and for as long as I've known her. We are also responsible for her medical bills and she is in the process of filing a claim on her 'back' as an injury that was brought about because of the injury to her ankle. The village, nor the fire department can afford this and over the next 34.5 years that she's suspected to live, we will have paid out more than a million dollars. My village and fire department are both in the process of potentially dissolving. Here's the thing, she is out and about... dancing and partying it up, but that doesn't seem to matter to Compensation. I can somewhat understand based on the explanation provided to me. However, what I can't understand is how she was given a medical release after her injury and was able to file a claim so long after the fact; what's to say she didn't get injured between her release and the filing of the suit? We're trying to speak with lawyers but are not having much luck and the Compensation people are saying that there is nothing we can do and all attempts are a waste of time and money. Please tell me they're wrong!

Cat


pagesvoice profile image

pagesvoice 3 years ago from New York/Pennsylvania border Author

@ tillsontitan - Thank you for the votes and I'm glad you enjoyed my story. Yes, I do have quite a few stories about my years in the insurance business. I was involved in compromise settlement cases and what many don't realize, the negotiations are more about how much money the attorneys involved want and less about the injured party's cash payout.


pagesvoice profile image

pagesvoice 3 years ago from New York/Pennsylvania border Author

tsmog - I was pleased to read that you enjoyed my story. Although many people clearly chart out a career path, many more just happen to fall into a job and it eventually becomes their lifelong profession.


pagesvoice profile image

pagesvoice 3 years ago from New York/Pennsylvania border Author

Cat - Thank you for stopping by and for your own story of someone who is clearly abusing and taking advantage of the system. I don't understand why the Comp. Board isn't doing more to authenticate or throw out this case. This is a great example of what the power of surveillance can do if implemented properly. It's a sad commentary how one person can ultimately bring a small area to their financial knees. Best wishes.


Cantuhearmescream profile image

Cantuhearmescream 3 years ago from New York

pagesvoice,

It is sad and it seems unreal. I think I'll bring up some surveillance options with the others; you never know! Thanks again,

Cat


pagesvoice profile image

pagesvoice 3 years ago from New York/Pennsylvania border Author

@ Cat - Small towns and villages are especially vulnerable to bankruptcies brought about by frivolous lawsuits due to fabricated/exaggerated disability claims. Again, I wish you all the best in trying to resolve the issue in front of you.

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