Here’s a great example of an investigation that turned up easy-to-find evidence that voided a very large insurance claim. So the insurance company didn’t have to pay a fraudulent claim void policy. This comes from Barry Zalma, he’s a high-end, very accomplished insurance claims investigator. And the nature of this case is there was a fire at this person’s house. Following the fire, the person put in a claim and said Hey my house was a total loss and I want you to pay me for my house and also personal property and furniture. When the investigation began it was discovered that the person that had the fire was behind on his mortgage payments and the houses for sale. Okay, that’s a red flag. It doesn’t mean there’s by itself there’s anything wrong but that’s a reason to look further.
So when the investigator looked at the property they did not find any remnants indicating there was any furniture that was in the fire. And an outside investigative, company came in and also verified there was no evidence of furniture or personal items being destroyed in the fire. This is one of the first things we do anytime there’s a claim of damage or fire loss or even a hurricane ask where were your pets? Where was your passport? Where were your valuables? And if the person says well they weren’t in the house, I took them out. Well, why did you take them out? Well, my Rolex was at the repair shop, my pets are at my friend’s house, and my birth certificate is in my pocket. Well, that’s a red flag. If the person knows there’s going to be damage they will take out things that are close to them.
So then the investigation got a copy of the proof of loss statement that said there was a couch loveseat and ottoman that he said he purchased from Ashley Furniture that was almost brand new. And he testified at an examination that this was an accurate representation of furniture that was reported lost as his property. And he moved into the home prior to the fire and this is where an investigator looking at this examination or this affidavit can really look at some of these details. So now the insurance company looked at this and says this appears to be false and they denied coverage. What they did was they did some other investigation and found that the insured’s girlfriend had submitted a claim under a furniture protection plan and obtained a replacement cushion for one of the sofas, meaning that the cushion either got stained or ripped or they had some kind of warranty on it and they got another one. The problem is this claim was put in nine months after the fire. The replacement cushion was delivered to a home where the insured and his girlfriend lived. So this investigation looked at this other evidence and looked at the original invoice for this furniture and at Ashley Furniture and found those a claim was put in for the warranty nine months afterward. This is where an investigation can help avoid paying out improper fraudulent claims. And of course, the insurance company moved for summary judgment and that the insurance was no good and that they didn’t have to pay the claim which means that this entire policy is void. So not only did they not get paid for the furniture, but they also didn’t have to pay for other parts of the claim. Meaning that that policy, says the entire policy is void when there have been fraudulent statements made.
So the insurance company made the argument that not only do we not have to pay for the furniture we don’t have to pay for the house either. So that investigation saved them tens or hundreds of thousands of dollars in insurance claims because it was falsely represented that he had lost furniture. You would think that somebody wouldn’t be that stupid but many, many times in fraudulent cases, a person is getting greedy especially if they’re late on their mortgage payments and under financial stress. And it voided the policy through misrepresentations. An investigation can many times provide more value than just the original fraud that’s being looked at. And if you have a good investigative agency that’s looking at all the details s lot of times it can be worth its weight in gold.
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