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Insurance Benefits fraud

Insurance Benefits Fraud

With the power to submit online claims through your smartphone comes great responsibility. The transition from submitting claims through the mail, with original receipts, to submitting claims electronically has changed the nature of claims, audits, and investigations. It is easier than ever to submit insurance claims for paramedical services, which opens the door for potential abuse and fraudulent claims.

Insurance companies use the data submitted by its plan members to identify and investigate fraudulent claims. Many insurance companies use sophisticated data-driven approaches. For example, Sun Life uses “big data” and analyzes claims to identify false or misleading information submitted by plan members. Suspicious claims, service providers, or clinics can be flagged. Social networks can be examined to identify relationships between plan members to see if a group of employees use the same “flagged” service provider or clinic. There are even algorithms that examine concentrations of claims, where a high number of treatments are claimed over a short period of time, and can even predict which service providers or clinics may be engaged in insurance fraud.

If you have been contacted by an insurance company, you may not necessarily be aware that you are under investigation. Insurance companies can perform random online audits, which may ask you to confirm whether services were provided. They can also contact service providers directly to confirm whether your claims are legitimate. In both instances, you are the subject of an investigation.

With the use of online claims and submissions, the data submitted to insurance companies can be used for purposes other than investigative analytics. In some circumstances, the data associated with your claims could be used as potential circumstantial evidence of fraudulent claims. Your username, password, online profile, IP address, and other information, such as the bank account that funds are deposited into form part of a record that could be used against you. The data you submit, knowingly or not, to the insurance company can be forwarded to your employer or, in certain circumstances, the police.

You can find yourself in a precarious position if you must choose between maintaining your employment and not making any incriminating statements that can be used against you. The protection under the Canadian Charter of Rights and Freedoms against self-incrimination does not apply to statements made to an insurance company, employer, or third party during an insurance fraud investigation.

If you are under investigation by an insurance company, your employer, or the police for insurance benefits fraud, it is critical that you speak to a lawyer. The lawyers at Damien Frost & Associates can help guide you through the investigation process and ensure that your rights are protected. Our firm can also help ensure that there is no misunderstanding with your employer or insurance company, so that your job is secure. Call us today to schedule a free consultation to learn about your rights and how we can help you.

By: Daniel Libman -

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