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Introduction1

Chapter 1What is Insurance Fraud?How Does the Law View It?3

What is insurance fraud?3

The United Kingdom3

Case law5

The burden of proof6

Perjury7

The United States8

Bad faith litigation10

Chapter 2The Typical Insurance Fraudster—Is There Such a Thing?15

Who is a typical fraudster?15

The “average” insurance fraudster15

The “criminal” offender15

Organised criminal gangs16

The motives for fraud16

Financial difficulties16

“Getting what we are entitled to”18

Chapter 3Insurance Fraud Indicators19

Insurance fraud indicators19

Property claims19

Disaster fraud20

Vehicle theft aud20

Casualty claims20

Staged accident fraud/personal injury fraud21

Chapter 4 Fraud in Insurance Law Generally23

Defining Fraud23

Objectives of the civil law23

Fraud in a civil context23

Fraud in contractual negotiations24

Post-formation fraud25

Fraudulent claims26

Fraudulent claims defined26

Use of fraudulent means and devices in the pursuit of a claim26

Something less than fraud?27

Substantial falsehood and the de minimis limitation27

Determining what is substantial28

Materiality and inducement29

Maintaining a non-genuine claim30

Suppressing a defence30

The consequences of making a fraudulent claim31

Express contractual provision31

No express provision32

The effect of fraud on the claim32

Rejections of earlier claims32

Rejection of any honest part of the claim34

The effect of fraud on the contract of insurance35

Damages36

Post-litigation fraud37

Chapter 5 Fraud in Marine Insurance Law39

Fraud in marine insurance law39

Fraudulent means and devices clauses in International Hull Clauses39

Materiality and inducement: the industry approach42

Maintaining a non-genuine claim43

Suppressing a defence43

The consequences of making a fraudulent claim43

Express contractual provision43

Rejection of earlier claims44

IHC and avoidance of the contract44

Post-litigation fraud45

Chapter 6 Fraud in the Reinsurance Law Context47

Fraud in the reinsurance law context47

The rights of the reinsurer48

Non-payment of the premium by the reinsured48

Express contractual provision48

No express provision48

Risk of affirming the reinsurance contract49

The inspection of the reinsured’s records49

Should court proceedings be stayed so that reinsurers may conduct an inspection of the reinsured’s records?52

Risk of affirming the reinsurance contract52

Audits53

Pre-contract audits53

Underwriting audit53

Claims audit53

Grounds for denying liability54

Types of fraud54

Incorrect circumstances surrounding the loss54

Inflated claims54

False description of the subject matter of the loss55

Statements concerning compliance with contractual conditions55

Notification of claims55

Payment of claims57

“Follow the settlements”58

What is it?58

The“follow the settlement”criteria61

To check coverage under the original policy61

To investigate the claim and settle it in a“professional”and“businesslike”manner61

Ex gratia payments63

Claims handling by agents63

That the loss is covered under the reinsurance contract64

Can the reinsurer still investigate claims where there is a“follow the settlement”clause?65

The reinsurer’s right to inspect the records of the reinsured65

What if the original insured has been fraudulent?66

What if the reinsured has been fraudulent?66

Claims co-operation clauses and“follow the settlement”clauses66

What is the position where there is no“follow the settlements”clause?68

What if there is no“follow the settlement”clause in the contract—can one be implied?68

Claims co-operation clauses and claims control clauses71

Claims co-operation clauses71

Claims control clauses72

Chapter 7The Insurance Industry’s Response75

The insurance industry’s response75

The UK approach76

The Serious Organised Crime Bureau77

The Association of British Insurers77

The Crime and Fraud Prevention Bureau77

Changing public attitudes to insurance fraud78

The ABI’s role as crime preventor80

The ABI“cheatline”81

Liaising with the police82

Fraud prevention databases84

The Motor Insurers Anti-Fraud and Theft Register（MIAFTR）84

The Motor Insurance Database（MID）85

The NSGenius database85

The income protection register（PHI）85

The premium instalment closed user group85

The art loss register86

Uninsured loss recovery database86

The intelligence database86

The Northern Ireland personal injury anti-fraud register（NIPAR）86

The Claims and Underwriting Exchange（CUE）87

Arson database88

Links Analysis software88

Does the Ombudsman have a role to play in relation to insurance fraud?88

Case summaries89

Case 21/189

Case 21/389

Case 21/490

The insurers’own initiatives in the fight against insurance fraud92

Internal fraud units92

Outsourcing of fraudulent claims investigations93

Computer and psychologically based fraud screening systems94

ICON94

Hunter95

Voice stress analysis95

Checking the validity of documents96

Claims replacement97

Example 1—“On your bike”98

Example 2—“Don’t drop your laptop”98

Example 3—“See you in Courts”99

Example 4—“All that glitters is not necessarily gold”99

Co-operation100

The future?101

Chapter 8Recent Developments—A Hindrance or a Help to Tackling Insurance Fraud?103

Recent developments—a hindrance or a help?103

Developments in the claims handling area103

Call centres—speed is of the essence103

The claims code104

Claims cards105

Computer-based developments106

Vehicle inspection equipment106

Selling insurance products over the Internet107

Settling claims over the Internet109

Legal developments110

The Woolf reforms110

Human rights/data protection111

Chapter 9The Approach of Other Countries to the Problem of Insurance Fraud115

The United States115

Staged accidents115

State action116

Reward schemes117

Convictions/punishments117

Insurance fraud bureaus118

The Massachusetts Fraud Bureau118

The New York Insurance Fraud Bureau119

The National Insurance Crime Bureau（NICB）120

The Federal Bureau of Investigations（FBI）121

Fraud prevention databases121

PILR（Property Insurance Loss Register）121

View Link Manager121

InfoGlide Fraud Investigator122

Claims Scoring Systems122

DBT Online Incorporated122

NetMap123

The effectiveness of fraud databases—some examples124

Predictive technology125

Layered voice analyser126

Legislation126

Fraud training127

Public perceptions127

Celebrating successes and rewarding efforts128

Insurers’ initiatives128

Fraud Defense Network129

The Coalition Against Insurance Fraud129

Outsourcing fraudulent claims investigations129

Canada131

The Canadian Coalition Against Insurance Fraud132

Public perceptions of insurance fraud132

Manitoba Public Insurance133

Australia133

Fraud prevention databases134

Reward schemes135

Litigation135

Legislation135

Case law136

New Zealand136

Fraud prevention database137

South Africa137

Fraud prevention database138

Fraud units/detection techniques138

Fraudline138

Continental Europe138

Europe-wide initiatives138

Germany139

Fraud problems140

Anti-fraud measures141

Call centres142

France142

Spain143

Italy144

Anti-fraud measures145

The Netherlands145

Switzerland146

Scandinavia147

Norway147

Sweden147

Denmark148

Finland148

Chapter 10 Conclusions149

Conclusions—tackling fraud—the way forward149

Anti-fraud bureaus149

Changing public perceptions of fraud150

More prosecutions of offenders by insurers151

Tougher penalties needed151

Closer work with the police152

Closer co-operation between insurers153

Closer co-operation with brokers153

Closer co-operation with other bodies154

In-house fraud units154

Call centres154

Internet insurance policies155

Marketing information155

Warnings on claim forms155

Make effective use of the information technology systems and databases available156

Vehicle repair systems156

Cheatlines/fraud lines156

Rewards schemes156

Data protection157

Reinsurers157

Bibliography159

Index167