Nebraska Department of Insurance

NEBRASKA DEPARTMENT OF INSURANCE INSURANCE FRAUD PREVENTION DIVISION 941 O Street, Suite 400 Lincoln, NE 68508-3639

Personal Injury/Bodily Injury Fraud Hints

It is important to remember that the hints listed below are merely possible "red flags" that there may be some evidence consistent with an insurance fraud scheme.  Any one or two of these by themselves, may not raise your suspicion; however, when you have several of these hints present or a pattern begins to emerge, you should investigate further or forward your suspicion to the Insurance Fraud Prevention Division.

1. No police report.
2. Police report indicates no injury at time of accident.
3. No report of injury at the time of accident.
4. Claimant/insured has a history of injury claims.
5. No claims for automobile repair made even though injury claims were filed as a result of an automobile accident.
6. Discrepancy between number of vehicle or people involved in the accident.
7. Conflicting statements as to cause of accident.
8. Extensive medical treatment associated with minor collision damage based on diagnosed subjective injuries.
9. Incidents involve rental or leased vehicles.
10. Three or four unrelated people in either vehicle.
11. The accident is a rear-end-collision caused by a sudden, unjustified stop by claimant's vehicle.
12. The accident has no witnesses and/or no debris or skid marks at the scene.
13. Claimant/insured is hesitant to meet personally with insurance personnel.
14. Claimant is reluctant to submit to an independent medical examination.
15. Claimant refuses diagnostic procedures that would substantiate injuries.
16. Claimant fails to keep appointments with medical provider.
17. Claimant is very familiar with treatment modalities.
18. Claimant provides medical/wage verification rather than a signed authorization.
19. Uniform treatment of all people involved in an accident for similar complaints by the same provider.
20. All claimants submitted medical bills from the same doctor or medical facility.
21. Medical bills are photocopies of originals.
22. Summary medical bills are submitted without dates and descriptions of office visits and treatments.
23. Treatment extends for a lengthy period without any interim bills.
24. Vehicle driven by the claimant is an older model with minimal coverage.
25. Medical bills contain alterations or additions.
26. Attorney's letters and medical specials arrive several months after the claim was reported.
27. Insurance company receives claims from several passengers even though the accident report reflects no passengers.
28. The attorney involved is frequently involved in questionable cases.
29. The claimant is represented by counsel at initial contact with insurance company.
30. Multiple attorneys represent claimant during the life of the case.
31. Medical provider referred by attorney or vice versa.
32. Same attorney/doctor for everyone in claimant's vehicle.
33. The injury is unrelated to accidental trauma.
34. Claimant's loss of consciousness is contradicted.
35. Insured, even though legally liable for the accident, is adamant about claimants being responsible, indicating that the insured may have been targeted by the claimants.
36. Physician's bill and report, regardless of the varying accident circumstances, is always the same.
37. Treatment prescribed is always the same in duration and type of therapy, regardless of the varying accident circumstances.
38. All injuries are subjective, such as soft tissue strains and sprains that don't heal in normal medically acceptable time.
39. Medical reports indicate inconsistent versions of the accident.
40. Medical reports show contradictory age and/or sex of claimant.
41. Medical reports indicate no acknowledgment of history of the condition, but preexistence of the condition is evident.
42. Diagnosed injuries are subjective, i.e., whiplash, headaches, spasms and persist for weeks or months without improvement.
43. Claimant waited several weeks before seeking treatment.
44. Claimant underwent extensive chiropractic treatment.
45. Course of treatment for long convalescent type injuries is not indicated by doctor.
46. Recovery is prolonged.
47. A major portion of expense is for diagnostic tests.
48. Medical bills indicate routine treatment being provided on Sundays or holidays or after normal hours.
49. Psychiatric tests subsequently submitted where original claim involved only trauma.
50. Large number of medical providers.
51. Experimental treatment modalities are prevalent on medical billings.
52. Medical bills are first-, second-, or third-generation photocopies.
53. Summarized medical bills are submitted without an itemization of office visits by date or type of service.
54. The doctor and the patient have the same last name and address.
55. Different ink or print types in areas of the medical bill that would normally be completed by one party or one office machine.
56. The claim is for the policy limit of coverage.
57. Medical treatments are consecutive during the week but always skip weekends and extended holiday periods.
58. Treatment for soft tissue injuries began day of, or day after alleged accident.
59. Claimant cannot recall name of medical provider, clinic, clinic location, or type of treatment.
60. Medical provider's office does not have licensed registered physical therapist, massage therapist, x-ray technician, nurse, or physician/chiropractic assistant.