Investigations: Private Investigator servicing
Toronto, Mississauga, Hamilton, Ontario, Canada

http://www.casiu.ca/articles.html

As reported by the ICBC in 2003, 15 percent of each of Ontarian's insurance premiums are attributed to the costs of insurance fraud, and this figure is supported by the Ontario Crime Control Commission. The cost of insurance fraud was estimated at $1.3 billion dollars in 2003--but the actual cost of fraud can only be estimated, as fraud is not always exposed and therefore the actual costs cannot be accurately recorded.

As a member of the Canadian Association of Special Investigations Units (CASIU), we realize that insurance fraud is very organized and continues to be on the rise. CASIU attempts to combat organized insurance fraud through the organization, education and networking to develop organized methods to fight the new trends in Insurance Fraud.

I became frightfully aware of the lack of public knowledge because day in and out I investigate these types of fraud. Then one day my neighbour who brought me back to reality approached me. He was involved in a motor vehicle accident on Highway 401 in the summer of 2003 and the first person on the scene was a tow truck driver. The tow truck driver attempted to entice this neighbour to take his vehicle to a specific body shop. Next, the tow truck driver attempted to convince my neighbour that he must be feeling injured and therefore treatment could also be arranged once the vehicle was towed to this certain shop. My neighbour refused to indulge this tow truck driver advances and demanded that his vehicle be towed to his own shop for repairs. Admirably my neighbor remained true. Being the honest hard working man that he is, he remained honest even though he could have made some extra cash out of the deal with the tow truck driver. The question is, how many other individuals would have caved into the almighty dollar, free housekeeping, child care, income replacement (tax free) and massage or chiropractic care even if they were not injured. In the mean time, who pays for it?

Interestingly enough, a tow truck driver could take in upward of $500.00 per injured party in the vehicle as a referral fee from the body shop, paralegal or the treatment facility. Even though these three occupations will pay the cash to the tow truck driver, eventually it will be embellished onto the insurance claim and again is attributed to the rise in our insurance premiums.

The paralegal's role is to complete the standard insurance forms and submit them to the insurance company. The paralegal submits the forms and builds the claim. The paralegal is sure to obtain an authorization form signed by the injured party. Driver beware that after these forms are signed, along with the accident benefit forms, you are now involved and could be implicated in any of the documentation that is submitted by your representative on your behalf.

To mitigate the file, the paralegal may submit wage loss forms, housekeeping and care giving expenses, in home assessment costs inclusive of assistive devices required along with the cost of your treatment plan. Your representative may also recommend the treatment at the rehabilitation center. Claimants are entitled to certain provisions under the Insurance Act and entitled to accident benefit coverage along with expenses for service providers. The invoices provided often are unsubstantiated and may be untruthful or falsified. Some examples of this abuse that exist today are listed below.

The injured person's employer may not exist and may not be registered with the Ministry of Consumer Affairs, failing that the company may be registered on the date that the accident benefit forms are presented to the insurer. At this point, bells in the ear of a good investigator will be ringing. As for the public, if someone is bragging it should be reported because the only people that pay for it are the insurance premium payers.

In some cases, a letter of promise to employ is submitted to substantiate wage loss. Yet, surveillance proves that the injured party continued to work at his employer, the same employer where the insured has worked for the past two years. To add to the untruths, the insured had not missed any time from work and actually attended the rehabilitation center at the same time that he or she was recorded working by the employer. Wage loss can be a substantial cost to the insurer and builds the cost of the claim.

Entitlements are plentiful. An unemployed person earns $185.00 per week and an employed person earns a percentage of lost income (the amount depends on the insurance coverage in place but could be up to 60% of the lost income) Needless to say, some of these unemployed parties are also collecting other assistance from the government or are possibly employed at other jobs, again costing us a substantial loss.

Delayed invoices for housekeeping and care giving are submitted to the insurer. The invoice for caregivers or housekeepers range from at $400.00 and up depending upon the alleged services the injured party is receiving. The words "delayed invoices" express the time frame in which the invoices are submitted to the insurer. Often these forms are sent several months afterwards so that investigation is delayed, as the insurer is not in receipt of any of the necessary documents to combat the possibility of fraudulent activity. The invoices are often submitted by the paralegal on behalf of the injured party. When investigated, we find that the service provider (housekeeper or caregiver) often has no time allowance due to their own regular schedule to facilitate for such services and in fact is only a friend of the injured person. Again the housekeeper or caregiver may be in receipt of government assistance and are not claiming the payment for this service to the government. Although the housekeeper's bills are 3 or 4 months old, they have never been paid. This is definitely questionable because there are very few service providers that will wait this length of time for payment. Would you?

An in-home assessment is arranged by the paralegal for the injured party to determine the necessity of assistive devices, capabilities and disabilities that the claimant suffers from. This assessment costs $900.00 to $1,200.00 for a two-hour assessment in the claimant's home and then recommends approximately $400 to 500.00 in assistive devices for the claimant to complete household duties. Items like a long armed duster, sweeper mop, pushcart laundry baskets, etc. and at the low price of $400.00. Another cost incurred by the Ontario Insurance Premium payers. The Health Professional that completes this assessment has limitations for billing under each individual profession and governed by the individual colleges for each profession. Unfortunately, the health professional is not ordinarily shown the In Home Assessment invoice submitted to the insurer and have no idea that the cost was even triple the amount of their own invoice. The bill is usually over embellished and unsubstantiated. Furthermore, other charges for transportation and translation are added onto the invoice. There is a bright light though, in recent cases, kinesiologists complete an in-home assessment. Kinesiologists do not have clear regulation for monitoring this profession and the hourly rate for the services are not controlled or limited. This could get expensive.

Next, the injured party attends a clinic (possibly recommended by his representative) signs the treatment plan, authorization forms, sign in logs and is examined by a chiropractor or massage therapist. A treatment plan is recommended and the Chiropractor never sees you again. The manager of the treatment facility may continue to submit invoices with chiropractic treatment that was never preformed by the health professional. Unfortunately, as an employee of the clinic, the chiropractor may not be permitted to observe the invoices and is unaware that his or her code continues to be used under the standard invoice for billing. To combat this problem, clinic audits of patients' files are completed.

Clinic audits are completed by experienced investigators and sometimes reveals startling over billing and poor record keeping. Some ghost clinics were audited. There was only a receptionist at the front counter, no equipment to facilitate treatment, no health professionals were to be found and no injured parties receiving care. The empty office containing business cards from another clinic in an office tower, where business can not be observed from the exterior without being in the hallway. How organized it has become. The treatment invoices continue to be generated to the insurer and as Insurance payers these cost trickles down to our premiums and the clinic owner reaps the financial rewards.

The invisible ghost patient also attends these types of clinics; they attend the initial assessment provided by the chiropractor, then are off to sign the documents. Sometimes signing months in advance, to foil the audit process but they have even signed on dates subsequent to the audit. Bookkeepers they are not, moneymakers and business people they are. Questions about the claimant's attendance, compliance and the cost of care not provided may have cost millions of dollars prior to Bill 198, which capped the abuse of over invoicing and costly clinic treatment plans. Since coming into effect, the cost has been regulated for the initial treatment plan and approval for any subsequent treatment plans.

So worse case scenario, how much is one car accident where fraud is not only the element but also the controlling factor? These figures are only estimated as fraud can never truly be measured and are believed to be lower than the average estimated costs.

Over the past week, we had more than 600 accidents and just say there was one person in each car and if every person utilized a fraudulent claim, this past would cost Ontario Premium payers $3 million dollars. After revealing this startling epidemic that surrounds us while we drive along Highway 401 or 404/Don Valley and along every street, please help us in the fight against fraud. It costs us millions of dollars. Please whenever you hear them bragging or you stumble upon a tip or you have an accident and learn of these fraudulent activities, REPORT IT.