Insurer Fraud corrupts from the top down and so do the profits. Until the insurance industry is held to the same standards the injured workers face, then it will always be profit before service, no matter who dies.
Insurer fraud is simply a business plan developed over the past twenty years. It was learned very early on that any attempt to deny benefits must be accomplished within the confines of the law or regulation in place at the time, or pay heavy fines/awards.
Insurance carriers pay serious fines, penalties, and jury awards for their illegal and fraudulent activities outside of workers’ compensation claims, but continue to “fine-tune” their effort to eliminate legitimate injury claims. They have found it more profitable because with no punitive damage awards in Workers Compensation, only the injured workers’ benefits are at stake.
Through legislative and regulatory manipulation, bribery, and fraud, Insurance Industry executives, lawyers, and lobbyists have turned today’s insurance policy into what was once termed a “Protection Racket”, much like the thugs in the early 1900’s. Today we pay for “protection” [insurance] that we cannot collect or depend on in a time of need. And, when a claim is filed, one must fear the retaliation of the insurance company that believes the money is theirs and we are trying to steal from them.
We continue to pay for insurance because the law mandates we have a policy for so many things; i.e. Auto, Health, Home, and Workers’ Compensation among others. Insurance companies have no fear of losing customers, just in having to pay claims. Therefore, they have been chipping away at the insurance laws and regulations. Their plan is to reduce benefits and eliminate claims through the most cost effective way possible.
In the past, insurance companies have paid for their mistakes through bad faith lawsuits in the area of Tort Law. However, policies written in the area of Workers’ Compensation are subject to what is termed the “Exclusive Remedy”. The concept of the Exclusive Remedy was to protect both the employer, as well as, the injured workers of California. It was established as a “No Fault” rule to provide immediate medical attention for those injured without subjecting the employer to lawsuits outside the workers’ compensation system. A great idea, if only they would keep their part of that historic bargain!
However, in the name of profit, insurance defense attorneys have exploited the Exclusive Remedy, turning it into a shield from prosecution for the insurance carrier, while allowing the them to act with limited financial exposure when applying fraud and deceptive business practices to the claim and benefit delivery process.
Insurance companies have spent billions of dollars in their effort to bamboozle and convince our lawmakers that injured workers represent the largest liability to the industry, not due to the claims made, but as a result of rampant worker fraud. While stuffing their coffers full of profit [in Billions] they profess to be concerned for the public and the great expenses passed on to employers, citizens, and the government.
The net result is we are now watching the lives of too many injured workers being ruined; they’re losing their homes, marriages are falling apart, and some even have been driven to commit suicide, suffering in indescribable excruciating pain as they face the unconscionable and illegal behavior of claim examiners, adjusters, private investigators, and defense attorneys.
The insurance industry has developed a subculture of like minded individuals who help facilitate the wholesale use of fraud within the workers’ compensation system; tools used by insurance companies to support their fraud.
On its face, the development of Utilization Review was a good thing. It was to assist in providing the proper treatment to the injured worker, while acting as “checks-and-balances” for medical providers who would “over-prescribe”; it was designed to prevent medical fraud and to keep doctors honest, not workers.
The establishment of the AME physician was also a good idea, but instead of objective, unbiased doctors, the insurance industry has aggressively recruited physicians of lesser quality, competence, and those willing to prostitute their credentials. For the most part, AME physicians are burnouts, washouts, or physicians who no longer wish to treat patients. They have also succumbed to the easy money of the insurance industry.
The same is true for the private investigators that have aligned themselves with the insurance industry. However, it is not the “Mom-and-Pop” Investigative Companies; it is the so-called “Nationwide Firms” that the insurance companies depend so heavily upon. Here again is the industry at work; as a continuation of the insurance industry business plan, many of these large PI Firms are comprised of former insurance company executives, claim examiners, adjusters, and supervisors with a single focus to provide profit retention services.
Moreover, many of the individuals in the field, currently investigating claims, are not truly Private Investigators. Most field personnel are untrained, uneducated, and UNLICENSED and are trained by insurance company representatives to perform a single function. Much like an assembly line worker, today’s private investigator is only a small part of the team insurance companies employ to eliminate legitimate injury claims.
Vocational Rehab is another fraud tool used by the insurance industry. The insurance company has found a way to manipulate the restrictions and limitations of an injured worker, provide minimal information, and receive yet another fraudulent document to “stuff” a claims file with.
Insurer Fraud requires the complicit behavior of many outside vendors, lawyers, and doctors. Without the cooperation of these individuals or entities the fraud could not continue to go unchecked.
The biggest failure in the workers’ compensation system is our legislative and regulatory bodies charged with providing and protecting. It would appear that providing and protecting has been utilized in the best interest of the insurance companies; after all who pays the most to be protected and provided for?
Ray Polly is a private investigator licensed by the California Department of Consumer Affairs - Bureau of Security and Investigative Services with 30 years of experience. He has over 60,000 hours of surveillance and investigative experience related to Worker’s Compensation, Liability (BI/PI), and undercover investigations in the areas of Employee Theft, Loss Prevention, and Workplace Drug Abuse. He has assisted the California Department of Insurance, the Department of Justice, and the California Highway Patrol in the criminal prosecution of insurance fraud by individuals, organized gangs, and legal and medical professionals.
