Facing the Music

Facing the music Stories

A file from the Claims Handling Income and Medical Advice department required further investigation. There were some indicators that showed that a further look into the facts was necessary. For example, the claims handler had noticed in a number of telephone conversations with the insured party that there were unusually frequent so-called “work related” noises in the background. Once is normal, but it was a little strange for it to happen every time.

This case relates to Joe B. became 100% incapacitated for work as a result of an accident two years ago, and has permanent problems with his foot and ankle. According to Joe, even just walking is hard. Walking up and down stairs, kneeling and those kinds of movements are no longer possible, or barely possible, or so the insured party claims.

Out with the bass guitar

Our initial investigation was conducted using so-called “open sources”, such as the Internet, the Chamber of Commerce and the Land Registry. This is how we discovered that, during his period of illness, Joe spent his free time playing in a rock band all over the country. Sometimes as a warm up act and sometimes as the main performance. He performed standing up with a bass guitar around his neck. We also found that he had participated as a guide in the Four-Evening Walk in his home town. But we were not done preparing a potential Personal Investigation. There were even more indicators to work through and we had to finish doing that first. Finally we reached a point where it was justifiable for us to begin a Personal Investigation in the form of an observation.

There are many decisions to be made before this can happen. It is of the utmost importance to take great care when you are about to literally follow someone. Observing a person is a specialism and must be done with the proper preparation. This is why an external agency is enlisted for an observation. We knew from the file that the B. family owned a dog. This is an important detail, because it tells us that the observer should not stand around in areas where the insured party might walk his dog. It’s all about the details, you see?

We used an observation bus and two other vehicles to see what Joe would and would not do. This was mainly to compare the things that he claimed he could not or no longer do with the observations of the external agency.

Long days on a building site

It was time to get started. A couple of observers had taken up their posts in strategic positions, ready to follow the insured party. We were rewarded for our efforts. At 5:30 am, a van drove into the street and stopped right next to the observation bus with its tinted windows. The observer was able to look the passenger in the eyes, but could not be seen himself.

Joe came out of his house, greeted the two people in the van as he got in, and the car drove off. The man in the observation bus now had to make his own way back, because the other observers had to follow Joe. The van was followed by the other observers and took a route that led to New York. Joe and his friends stopped at a petrol station on the way, to get petrol and buy coffee and sandwiches. It was 6:15 am and it was getting harder for the observers not to be discovered now that it was getting light.

Finally the van arrived at a large building site, where Joe and his two colleagues went to work all day. Joe stood, bent over, lifted, bent his knees, nothing was too much for him. Except that this directly contradicted what he had told us in the past.

Sometimes it was clear that he was trying to relieve some of the pressure on his foot, but still… Joe worked long hours from 8 am until 3 pm, after which the van dropped him off at home. This pattern was repeated several times and the picture gradually became clearer to us: Joe was receiving monthly compensation that he did not deserve. In total, Joe was observed three times, for two days at a time, and his life looked entirely different to the way he had portrayed it in his file.

One of those times, it was difficult for us to observe him properly, and an observer had to hide in the bushes. In the end, all of the findings were recorded, including some high quality video. We assessed these and then ran them past the medical advisor. After reading the report and watching the video footage, we could confirm that this didn’t match the story Joe told.

Found out

Joe was confronted with all of the findings and we showed him the video footage. He admitted that he had done the wrong thing. Still, he came up with all of the excuses that we had already heard.

What Joe had not considered was that he would have to pay us back all of the undeserved compensation that he had received as well as the costs of the investigation. It should go without saying that his disability insurance was cancelled. We also reported him and, importantly for us, the claims reserve of several hundreds of thousands of Dollars was released.

After a few months we contacted Joe to see how he was doing. He was paying the agreed monthly amount in repayments to us and that shows goodwill. In the end, we came to a solution together.

Is Joe a professional fraudster? No, Joe is a hard worker who made a really stupid mistake.

Did Joe commit fraud? Yes, he certainly did, but he has also learned his lesson and that is why we had a positive discussion with Joe later on.

Joe and his family can continue with their lives, but it was an expensive lesson to learn…

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