This first contact for details sets the tone of the relationship which should be positive. It is a snapshot in time as to relevant details, and in that small but significant percentage of claims where fraud must be identified and dealt with, it also helps gather useful information.
False information submitted in furtherance of a claim seems to follow national employment averages. For instance, in their efforts to secure employment, it is estimated that CEOs and CFOs submit inaccurate information between five and fifteen percent of the time. The range variance relates to the level of lying that takes place. Michael Josephson, President, Josephson Institute of Ethics, Los Angeles says, “lies are like potato chips. You can’t tell just one!” Among non-supervisory employee applicants, résumé falsification is estimated to occur between 22% and 25%, and most of the falsified information goes undetected. It stands to reason that if employees are willing to submit false information to secure a job, given the opportunity, a significant percentage will submit false information with regard to insurance claims.
Last year’s estimated annual losses against businesses, individuals and the government due to fraud were over $600 billion. Of that, insurance fraud accounted for an estimated $185 billion or the second highest fraud loss behind income tax invasion. The US Department of Commerce and the Association of Certified Fraud Examiners estimate that one in five businesses fail in the first five years of start up due to fraud.
These numbers are staggering and seem difficult to comprehend, but losses due to insurance fraud can be reduced by a number of fraud fighting techniques. One of the most effective is claims-related interviewing.
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The importance of Good Listening
First and foremost a good claims interviewer is an effective listener. One can obtain more accurate and complete information through simple listening. Getting in the habit of allowing the claimant to complete his or her entire answer without injecting the next question is critical.
Police interrogators have long studied how to formulate questions for the purpose of eliciting accurate responses. For instance, how suggestive a question may be can definitely influence a person’s response. Most often, police have found that witnesses who are asked to describe an event in their own words provide their best understanding, and their thinking is not shaped by a complex question presented by an interviewer. In other words, if you as an interviewer first listen to a full story by a claimant and then follow it up by specific passive questions triggered by careful listening, you should get the most accurate and complete information from the claimant.
What to do
1. Ask simple questions such as “what happened?” Again, let the claimant completely respond uninterrupted. Ask follow up questions based on missing elements of information provided.
2. Most people speak at a speed of about 125 words per minute. This is extremely slow compared to what the brain can handle. A poor listener’s thoughts many times drift away into daydreams or outside thoughts. To aid concentration, a listener should use the extra thinking time to think ahead of the talker, formulate ideas on where the talker is headed, and connect that information to what has already been said.
3. There is a strong tendency to make a quick evaluation without first getting the full meaning. Patient listening should be followed by questions to increase the interviewer’s understanding of the claimant’s background.
4. Most claims interviews are conducted by telephone. When, however, a telephone interview sparks a suspicion of fraud, take steps to conduct a follow-up interview in person. The listener’s own actions, i.e. body movements, eye contact, hand gestures, head nodding, facial expression and tone of voice must convey to the claimant an interest in what is being said and an interest in the claimant as a person. Leaning towards the claimant conveys the non-verbal signal that the interviewer is interested, even enthused, about the information being provided. This approach can set a claimant at ease and open the door for further inconsistent information.
Planning
Planning the initial claims interview ahead of time is key. This would include reviewing as much information as possible about the claim in advance and thoroughly debriefing the insured for details. Learning as much about the claimant as possible in advance helps develop confidence on the part of the interviewer and allows the claimant to be set more at ease. It also allows the interviewer to maintain control of the pace and the subject matter.
Breaking the Ice
Setting the tone of the interview is important. Again, putting the claimant at ease should be your initial goal. Once done, “chase” the claimant for details to support each aspect of the claim. A great icebreaker is to open the interview by asking the claimant to tell you about themselves. This usually allows them to start talking without worrying whether their answers are correct. Some people may be so nervous about the interview, that you have to work harder at putting them at ease. If asking them to talk about themselves doesn’t work, you may try asking them about hobbies, a local sports team, news, weather, or anything that you can think of to open them up.
You know that you have been successful in getting them to relax when they verbally warm up and begin to offer information that’s not necessarily on point. If you are conducting the claim interview in person, you will notice that they will start to smile, breathe deeper, and drop their shoulders a bit. It is at this point that they will begin to display their true feelings.
Along similar lines, and preliminary to the questions relating to the claim, ask a question that really has no right or wrong answer. This tactic will allow you to hear how the claimant will talk, reason and analyze issues. It might even give you some insight into them. It can also be a useful method to let claimants tell you about something they enjoy outside of work, something important to them or something they cherish. This type of conversation can be quite revealing.
Understanding and Questioning
The ultimate goal of the interview is to formulate an opinion regarding the facts of the claim. It is important to remain objective at all times. It is helpful to gain an understanding of someone’s motivation, especially when his or her statements can be independently confirmed.
It is also very important not to run out of questions before the interview is over. Repeat a question if necessary while formulating another one. Sometimes, however, a long period of silence makes the claimant feel as if he/she should fill the gap. In these instances, a claimant can provide more information than he or she intends.
If there is an area in conversation where the claimant becomes uneasy, continue to inquire about that subject. Behaviors including yawning, giggling, evasive answers, audible stomach noises, etc. may be coincidental, or they may relate to untruthful responses.
Observation
If a follow-up interview can be conducted in-person, observe the actions of the claimant for physical behaviors which may indicate deceptiveness. People providing untruthful responses will display certain body reactions which are visible to the trained interviewer.
Begin the interview by shaking hands and introducing oneself. Sit close enough so that your very closeness to the claimant causes a certain amount of uneasiness. The distance should be far enough away, however, so that you can observe his/her movements and actions from head to toe. Do not put a desk or a table in between you and the claimant. Look for physical signs of nervousness which would include sweating, and/or the inability of the claimant to look you in the eye. It is most important that you maintain eye contact throughout the interview in order to determine if this reaction is coincidental or if there is a pattern to it.
Take Your Time
Don’t rush! Don’t be too quick to complete the interview. This will be the best opportunity to gather details about the substance of the claim, and it will also offer the best chance to uncover any inconsistencies.
Take good notes throughout the interview. At the end, review those notes for thoroughness and repeat anything to confirm understanding.
Those interviewers who are good at developing an intuitive sense about a claimant’s information are generally persons who have a better understanding of those around them. Every statement has two components, content and emotion or attitude. Those interviewers who have the most success at eliciting truthful responses are the ones who possess these important communication skills and have chosen to invest themselves in the interviewing process, looking at it as a rewarding experience rather than a study in frustration.
Depending on your company’s policy, in the event that a suspicion of fraud develops, immediately take steps to lock the claimant’s statements in by taking extra time to legally record his/her remarks. You have already verbally locked them in, and they will more than likely repeat what they said during the course of the interview. That recording can be a powerful piece of evidence in developing a defense against the fraudulent claim.
And Finally
Last summer the Michigan Supreme Court issued its opinion in Sington v Chrysler. The majority opinion discussed the issues of wage earning capacity and what constitutes a disability. There has been a reaction in the insurance community to gather a more complete history about the claimant, and more completely define the claimant’s background, qualifications and training according to guidelines set forth in the Sington decision.
Many insureds provide claims staff with contact sheets to complete with information elicited during the course of an interview with claimants. The following questions may be appropriate for use in your contact sheets in light of the Sington decision and assist in the overall investigation of the claim:
1. Name your high school and college institutions?
2. Level of education accomplished?
3. Did you play any sports in school (name them)?
4. What is your past work experience (name jobs and place of employments)?
5. Dates of employment at each employer?
6. Name your normal duties at each of your employers?
7. What training and qualifications did you need to perform this job?
8. Physical and mental requirements of each employment?
9. Any prior specific or additional training at any time on any of your prior jobs?
10. Does it qualify you for perform other work?
11. If so, are you qualified to perform this work?
12. Amounts that you have been paid for your past jobs?
13. Since your injury, were any other jobs made available to you by your employer?
14. Have you been offered any other jobs lately?
15. Where, when?
16. Are you able to do any job with restrictions? What?
17. Have you ever filed a worker’s comp claim or any other claim before? Details?
18. Any non-occupational injuries in the past?
19. What are your hobbies? (Hunt, Bowl, Camp, Fish, Golf, Race)
20. Do you hold any special licenses within the state of Michigan?
21. Do you or your spouse own any of the following, motorcycle, boat, recreation vehicle (r.v.), and/or camper?
22. How do you and your family spend spare time together?
23. Any annual vacations? And where? Any upcoming vacations planned?
24. Do you rent any property at any time throughout the year?
25. Name all properties you own?
26. How many vehicles are typically at your residence? What kinds? Are they manual or automatic? (important with leg or back injuries)
27. Do you have any children? And ages?
28. Where does your spouse or live-in work?
29. Have you ever used another name?
30. Have you ever lived in another state?
31. Explain how the accident happened? here were you, what time, any witnesses, who did you tell at work about the injury? (this will help you find contradictions in medical reports)
32. What you were doing at the time of the accident, was that part of your normal daily job?
33. At the time of the accident, were you horse playing? ( An accident at work caused by horseplay may not be compensable)
34. Are you right or left handed?
35. Do you drink or smoke?
36. Do you know your neighbors well? Are they close friends?
37. Get picture of claimant (driver’s license)
Of Course any in-house questioning format should be reviewed by house counsel and supervision.
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