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(1)

Utah Department of

Insurance

Fraud Division

Armand Glick Director

(2)

Insurance Fraud Division Staffing

11 – Law Enforcement Special Function

Investigators

3 – Assistant Attorney Generals

2 – Legal Secretaries

(3)
(4)

Investigation Diversity

FY 2013 Total Referrals - 676

Agent Fraud 43 False Property Theft 82 Application Fraud 60 False Auto Theft 35 Healthcare 29 Staged Collisions 7 Exaggerated Injuries 31 Vehicle Arson 5 Doctor Shopping 6 Inflated Loss/Damages 15

Prior Injuries 11 False Damages 16 Slip and Fall 4 Property & Casualty -

Other 274 Other 55

(5)

FY 2013 Case Types Received

37 50 28 13 21 25 30 44 24 Agent Fraud Application Fraud Exaggerated Injuries False Claims False Loss

False Property Theft False Auto Theft

Staged Auto Accidents Medical Other

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0 10 20 30 40 50 60 70 80 90 100 Misdemeanor B Misdemeanor A Felony 3 Felony 2

FY 2013 Charges Filed

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FY 2013 Restitution Recovery

$100,000 $200,000 $300,000 $400,000 $500,000 $600,000 $700,000 $800,000 $900,000 $1,000,000 2010 2011 2012 2013

Out Side Victim Restitution

Investigative Cost Victim Restitution

(8)

Current Trends

Insurance Agent Fraud

False Auto Glass Claims – Sales Agent Fraud

Staged Auto Accidents

Past Posting Claims

(9)

Agent Fraud – Identity Theft

Using SSN and Birth Dates

of prior applicants to obtain

better credit scores for new

applicants

Increase new customers

Qualify for bonuses

Remove false person after

(10)

Pocketing Premiums

State vs. Rodgers

– Commercial Liability – $22,500 Restitution

– Pled Guilty (3) 2nd Felonies

and (2) 3rd Felonies

– Concurrent 1-15 years Prison

(11)

Pocketing Premiums

State vs. Kelling

– 50 years – family business – Commercial Liability

– Auto Coverage

– $86,000 Restitution – Still identifying victims

(12)

Agent Fraud – Fictitious Policies

• State vs. Kartchner  Created False Policies  Collected Undue Commissions  Farmer Bureau  $ 56,000

(13)

Agent Fraud - Forgery/Theft

• State vs. Mijares

• Created False Documents to Reduce Insured Premiums

• Altered Insured Cancellations to Obtain Refund – Kept by Mijares • Farmers Insurance

(14)

Cross Boarder Sales

Example

– Selling Nevada Annuities to Utah Residents

– Listing PO Box as Resident Address

– Using Alternative ID Forms on Application

(15)

False Insurance Sales

State vs. Brady

$479,123 Total Loss

82 Victims

Brady sold home warranties to new home buyers during the closing process. Issued false certificates of insurance from a company that did not exist but was similar in name to a real company. No

(16)

Escrow Agent Case

State vs. Blake

– $800,000 loss

Blake kept closing money and did not pay off buyers old accounts. Placed money in personal account. Fabricated documents to provide buyer evidence loans had been paid.

(17)

Inflated Loss Collusion

State vs. McFarland

$6,000 Loss

McFarland inflated value of vehicle for a friend

involved in an accident. Payout larger than

vehicle loan value. Had two checks issued.

Owner gave McFarland some of the proceeds

from the fraud.

(18)

Claims Adjuster Fraud

State vs. Phillips

– Accident claims adjuster.

– Created false additional damage estimates for auto vs. animal accidents.

– Had payment checks made to her husband.

– Had payment checks sent to her home address. – $23,963 loss.

(19)

Staged Accident Prevention

Inspect Vehicles at

Policy Inception

Obtain Positive

Identification

Obtain Proof of

Ownership

(20)

Soft Fraud vs. Hard Fraud

Where do you draw the line?

CPT Up Coding & Unbundling Excessive Treatment Duration Excessive Services / Unnecessary DOS Abuse of Diagnostics Fraudulent CTP Coding Falsifying Medical Records Billing for Services or DOS Not Performed or Ghost Patients

Spectrum of Fraud

Soft Hard

(21)

Billing Services Not Provided/Altering

Medical Records

State vs. Paxman

Victims: EMI, PEHP, Medicaid - $44,000

(22)

Billing Services Not Rendered/Forgery

State vs. Penegar PEHP

(23)

Falsely Listing Boyfriend as Spouse

• State vs. Strickland • Cambia, Altius,

Select Health

(24)

Faked Injuries/Finance Fraud

• State vs. Brown

• Emergency Room

Visits

• Paid with Bad Checks

• GEICO, Farmers, IMC

(25)

State vs. Guillen

State Farm Insurance $48,000

(26)

WC Death Benefits after Re-Marriage

• State vs. Perry

• Trans America Life • Total Loss: $60,000

(27)

State vs. Christensen

AAA Insurance $42,000

(28)

False Auto Glass Claims/Identity Theft

• State vs. Crose/Precise Auto Glass • 100’s of false claims • Impersonated the Insured • Farmers, American Family, Farm Bureau • Total Loss: $6,000

(29)

Staged Vehicle Burglaries/Thefts

• State vs. Sullivan

• Allstate, Homesite,

Safeware, Allianz, IDS,

Travel Insured, Tru Travel, Old Republic, Travel Guard, CSA, Tripmate, AMEX

• Attempted Theft - $107,000 • Obtained $68,000

(30)

Staged Vehicle Theft - Owner Give Up

(31)

Staged Auto Theft/Arson

State vs. Lopez

American Family Insurance $3,346

(32)

Uninsured Loss/Past Posting

• State vs. Smith

• Water Damage Loss • Reinstated Insurance

-then filed claim • Allstate

(33)

Staged Burglaries/Hurricane Damage

• State vs. Jhamb • Alta – New Jersey • Allstate, Selective

Insurance, Metlife, Veri Claim

(34)

False Auto Damage Circumstances

• State vs. Ngoyi & Warner • GEICO

(35)

Questions / Contact Information

Utah Insurance Department Fraud Division 230 South 500 East, Suite 170

Salt Lake City, Utah 84201 801-531-5380

References

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