Law of Claims Fraud Investigation and Defense Program
The LAW OF CLAIMS FRAUD INVESTIGATION AND DEFENSE PROGRAM is a comprehensive treatment of fraud as it relates to casualty, property, and workers' compensation claims. The Program is essential for all claims professionals, fraud investigators, and special investigative unit personnel. It presents a well balanced approach between early fraud recognition, referral for special investigation, and understanding of insurance policy requirements in order to combat fraud effectively while, at the same time, honoring policy obligations.
NOTE: All courses required for Program completion.
510 Recognizing Fraud
(Course Textbook Consists of 152 Pages)
This course will enable the student to identify the fraudulent claim and begin to take the steps necessary to deal with it. The materials include a discussion of the elements of fraud, misrepresentation, concealment, false swearing and arson. Different types of fraud are discussed, including padding, bogus claims and other common schemes. Resources such as fraud indicators and databases, available to assist in the identification process, are also covered.
2. The Insurance Contract and Insurance Fraud Law
3. Types of Fraud
4. Recognizing Fraud Potential
511 Special Investigation
(Course Textbook Consists of 198 Pages)
This course will enable the student to understand the role of the Special Investigative Unit (SIU) in dealing with fraudulent claims. Emphasis is placed on the legal limits of the SIU investigation as it relates to undercover operations, informants, entrapment, etc. Also discussed is the role of the SIU in obtaining commitment to the fraud, corroboration of it and finally, confronting the insured or perpetrator to obtain the desired confession of fraud or, at least, withdrawal of the claim.
1. Good Practices in Handling the Special Investigation
2. Special Investigation Techniques
3. Proactive Investigation and Its Limits
512 Proving Fraud
(Course Textbook Consistsof 138 Pages)
This course will enable the student to understand how to prove fraud legally. This, inturn will enable the student to channel investigative efforts toward the legal proof that may eventually be required if litigation ensues. The discussion includes burden of proof, evidence of prior and subsequent incidents, constitutional issues involving the Fourth, Fifth and Sixth Amendments, and the effect of criminal proceedings on a civil action.
3. Discovery and Privilege
6. Constitutional and Criminal Law Issues
513 Handling Suspicious Claims: The Policy and Its Requirements
(Course Textbook Consists of 165 Pages)
This course will alert the student to key policy language and how it affects the investigation of a fraudulent claim. First, the construction and application of the policy language is discussed. Next, specific policy provisions such as notice, proof of loss, and examination under oath are considered. Finally, the insurer's remedies are reviewed. These include rescission of the contract, denial of the claim, pursuit of restitution, and criminal sanctions.
1. The Policy as Contract
2. Insurer's Duties
3. Policy Conditions
514 Avoiding Bad Faith and Civil Liability in Handling Suspicious Claims
(Course Textbook Consists of 178 Pages)
This course will enable the student to understand how to avoid the imposition of liability during the investigation of fraudulent claims. First and third party bad faith is discussed. Other tort actions are also considered such as defamation, invasion of privacy, and malicious prosecution. Emphasis is on ways to pursue the fraud investigation while exercising good faith.
1. The Cause of Action for Bad Faith
3. Other Theories
4. Good Faith and Other Defenses
515 Advanced Legal Issues in Fraud Investigation and Defense
(Course Textbook Consists of 150 Pages)
This course will further the student's understanding of legal issues relating to fraud investigation and defense, including the sharing of information with law enforcement and other insurers, investigation techniques geared to avoiding defamation and other torts, and understanding how legal rules such as hearsay and evidentiary privileges affect the usefulness of evidence that might ultimately be used in court to defeat fraudulent insurance claims.
1. Managing Information to Avoid Defamation
2. Using Information
3. Reasonable and Effective Special Investigations
516 Auto Insurance Fraud
(Course Textbook Consists of 167 Pages)
This course, written by a special investigator who investigated suspicious automobile claims for over twenty years, will enable the student to identify most of the automobile insurance fraud schemes and scams currently being perpetrated, understand how they work and how to investigate and defend against them and those who seek to profit from them. The materials cover auto fires, auto theft, physical damage, and bodily injury claims. Many case examples of actual fraudulent schemes are included.
1. Introduction To Auto Insurance Fraud
2. Auto Theft
3. Auto Fires
4. Auto Physical Damage Fraud
5. Auto Accidents and Bodily Injuries