Course Introduction

MODULE 1 – INSURANCE AND INSURANCE FRAUD

In this module you will get a basic understanding of insurance fraud, its historical significance, the role of insurance fraud investigators, both as carriers and professionals, and a deep understanding of the Code of Ethics. The module also covers the Insurance Fraud Prevention Model Act and the steps involved in the expert selection process, a critical part of the insurance fraud investigation domain.

MODULE 2 – TYPES OF FRAUDS

This module will equip you with knowledge about insurance fraud types, providing an in-depth understanding of health insurance fraud, car insurance fraud, home insurance fraud, life insurance fraud, worker compensation fraud, and instances of fraud perpetrated by insurance companies. This module will help you to gain insights about the techniques employed across different sectors of the insurance industry, focusing on the multidisciplinary approach of combining forensic accounting, data analysis, and vigilant regulation to safeguard the insurance industry from fraudulent activities.

MODULE 3 – INSURANCE FRAUD INVESTIGATION FRAMEWORK

This module explores the role and duties of an insurance fraud investigator, including locating information sources, gathering and examining records, and conducting insightful witness interviews. In this module you will also learn about the significance of meticulous witness preparation for a systematic investigation. This module offers a step-by-step guide that will equip you with techniques to prepare witnesses effectively and build a solid case against fraudulent activities.

MODULE 4 – UNDERSTANDING INSURANCE POLICIES

This module focuses on the intricacies of insurance policies for fraud investigations. This module starts with an introduction to the language and contractual nature of policies, helping you to identify potential loopholes and assess evidence effectively. It then explores first- and third-party policies, focusing on distinctions that mold the dynamics of coverage and claims. The module also introduces the concept of the innocent co-insured, shedding light on the complexities and legal challenges that can emerge in insurance scenarios.

MODULE 5 – INTERVIEW PROCESS IN INSURANCE FRAUD INVESTIGATION

This module will take you through the process of extracting essential information following a systematic approach. The module emphasizes the significance of the preliminary statement from the insured or claimant in understanding the context. It also covers various statement methods, like preparation techniques, active listening, and maintaining control to extract accurate and detailed information. In addition to this, effective approaches to obtain witness statements will also be taught.

MODULE 6 – INFORMATION GATHERING AND LEGAL ISSUES OF SHARING

This module will equip you with the knowledge about various methods to gather and analyze information, including the Immunity Reporting Act (incentivizing individuals to come forward with information related to fraud), the Public Records Act (facilitating investigators to access essential data for in-depth scrutiny), and reciprocal information exchange (exchange of insurance contracts between individuals and businesses).

The module explores different information-gathering methods, like historical website searches, newspaper investigations, and examining city or country business and professional licenses. These techniques will enhance your understanding of the investigative process and help in finding potential fraudulent activities.

MODULE 7 – CONDUCTING SURVEILLANCE

Surveillance involves careful monitoring of a person or place by law enforcement to investigate a crime or prevent its occurrence. In this module, you will gain insights about surveillance methodologies specific to insurance fraud investigations, including preparation steps and techniques for both foot and vehicle surveillance to ensure effective evidence gathering.

The module also explores fixed and moving surveillance, night surveillance, satellite surveillance, single-vehicle and two-vehicle surveillance, video surveillance, tips for conducting robust surveillance, and the role of vendor management, highlighting its significance in insurance fraud surveillance operations.

MODULE 8 – HEALTH INSURANCE FRAUD INVESTIGATION

This module explores the nature and scope of health insurance fraud, highlighting common fraudulent activities such as false claims, billing for services not rendered, and overbilling. You will also learn about the various types of health insurance fraud, including provider and policyholder fraud, along with the process for detecting and resolving these frauds, supported by case studies and relevant case laws to offer real-world applications and legal context.

MODULE 9 – LIFE INSURANCE FRAUD INVESTIGATION 

In this module, you will learn about the nature and scope of life insurance fraud, examining various fraudulent activities such as policy misrepresentation and death benefit scams, different types of life insurance frauds, the investigation process for detecting life insurance fraud, along with techniques for identifying fake or inflated healthcare claims. Real-life case studies and relevant case laws are also discussed to provide practical insights.

MODULE 10 – PROPERTY DAMAGE AND THEFT CLAIMS INVESTIGATION 

This module focuses on the investigation of property damage and theft claims, exploring the scope and nature of property damage. It covers various types of property damage, including accidental, intentional, and environmental. Additionally, you will learn about the investigation process for theft claims and the impact of natural calamities on property damage and insurance claims. This will provide you with valuable insights into loss assessments.

MODULE 11 – MOTOR VEHICLE ACCIDENT CLAIMS INVESTIGATION 

This module explores investigating motor vehicle accident claims, including their nature and scope, along with different types of motor vehicle accidents. You will gain insights about the role of the Motor Accident Claims Tribunal (MACT) in resolving disputes and the investigation process for accidents. Emphasis is placed on identifying fraudulent claims, reconstructing accidents, and analyzing evidence to ensure fair outcomes and accurate claim resolutions.

MODULE 12 – CASE-ORIENTED INSURANCE INVESTIGATION 

This module covers various case-oriented insurance investigations, including fraudulent disability, premise accident, railroad crossing, and suicide investigations. It emphasizes the importance of thorough investigations to identify fraud and ensure accurate claim assessments. The role of photography in documenting evidence and supporting case analysis is also covered, highlighting its necessity to enhance the credibility and clarity of insurance investigations.