Copyright held by The John Cooke Fraud Report. Reprint rights are granted with attribution to The John Cooke Fraud Report with a link to this website.
By Tim Bullock
It’s that time of year. The approach of winter weather and the yearend holidays coincides with what has become an insurance industry nightmare the migration of claimants who wish to visit home and family at the expense of honest businesses. Migrant workers, illegal workers and criminal aliens generally begin to head home at about the same time that most Americans are feasting on roast turkey, homemade stuffing and pumpkin pie.
California, Arizona and Texas receive an abundant share, but the problem stretches across the USA. It begins with aliens entering the US illegally and proceeds with the fraudulent acquisition of documents which permit work. Certain street corners become known throughout the illegal community as locations dealing in the sale of bogus documents. For a price, one can purchase an employment authorization card, a social security card or almost anything else. The skills necessary to produce such items are not what they once were because computers and laser printers provide a technological advantage and make it difficult to discern the real from the not so real.
In any large metropolitan area, be it New York, Boston, Atlanta, Dallas or Los Angeles, minority ethnicities will define geographical communities. This serves a variety of purposes. Foremost is the comfort level afforded by a familiar community. But a side effect is the communication that occurs throughout the population. If a scam works for one person, the news is quick to travel.
One popular scheme is to take a vacation funded by the workers’ compensation or disability insurance system. Work related subjective injuries are claimed back pain or strain, sore necks, shoulder joint problems, etc. and the checks start arriving. In some cases, other avenues of collection are also pursued, including welfare, public assistance and more.
Not only does the employer suffer on the workers’ compensation premium front, but if the INS or IRS becomes part of the investigation, the employer can also be fined for accepting an employee with false identification and work papers. No matter how good the forgeries may be, the employer may find himself ultimately responsible.
This scenario poses a difficult dilemma for the investigator. An insurance fraud case may be made far stronger by involving the federal authorities in the investigative process, but if the ultimate price paid is a hefty fine for the employer, the renewal may be lost for that company. There are few business owners who have the presence of mind to say, “Thank you for arranging for the IRS to take a very close look at my operation. And sending a team of INS agents in was so very kind of you and I really appreciate your efforts at cleaning up my hiring practices.” Unfortunately, the vast majority of business owners will react in a slightly different manner they pick up the phone and scream colorful profanities as they cancel every policy they have ever purchased with that company or that agent. Remember, the feds get three out of four cases from sources other than themselves, so involving state or federal agencies in your investigation must be weighed, pros vs. cons.
Situations such as the above place the SIU investigator in a precarious position. On the one hand he would like to defeat the fraudulent claim, but on the other hand he may have to limit slightly his use of all available resources. What are some of the things that he can do?
First, he can respond to the case immediately. The ultimate difference between responding within a matter of a few days or a week or more can turn out to be immense. Whether the claim is a workers’ compensation case, a liability issue or a bogus medical claim, the SIU investigator should get to the claimant as soon as possible and lock that claimant into a statement. Additionally, all witnesses should be interviewed as quickly as possible, while the alleged facts of the accident are still fresh in their minds.
If a claimant reports that he fell on the floor during work hours on July 31 and twisted his back so badly that he was unable to complete the day, the best interview results will be obtained if people are questioned within the week. If the investigator asks a potential witness on a Thursday about what the witness remembers from the previous Monday, chances are good that more details will be recalled than if the questions are directed around the happenings of a week or more in the past. Simply stated, the faster the investigator can obtain the necessary statements, the better the chance there will be of defending a potentially fraudulent claim.
Answers to specific questions will vary with the time elapsed between the event and the statement as well. Consider the following two examples:
#1 Investigator is interviewing a witness three days after the occurrence.
I: All right, Fred, where were you at 2:00 PM on Monday?
F: Monday? Let’s see… I started my break at 2 and went right to the pay phone by the north entrance so that I could call my wife. She had a doctor’s appointment on Monday and I wanted to know what the test results showed. Lucky it was a bladder infection and you know how…
I: (Interrupt) Tell me your exact route to get to that phone.
F: Well, I walked down the steps just behind my work area and then took the long way around the rear of the building because they’ve been fixing the leaks in the ceiling all week and you can’t get through there. You gotta walk right through the vending machine area and cut out the back exit there.
I: And did you see Hector Gonzalez when you walked to the phone on Monday?
F: Sure did. He was in the vending area eating a burrito. I remember thinking he must be crazy, because it was Monday and the food delivery guy hadn’t been there yet; so the burritos had been sitting in the machine since at least Friday. When they’re fresh, they’re pretty gross. When they’re three days old you can’t tell if it’s green sauce or mold on ’em.
I: Did he appear to be injured?
F: Not that I could see. He was just sitting there reading the paper and eating that nasty looking piece of vending machine cardboard…
Or
#2 Investigator is interviewing the very same witness, but in this case three weeks has elapsed since the alleged occurrence:
I: All right, Fred, where were you at 2:00 PM on Monday the 12th of September?
F: Monday the 12th? Hmmm. I might have been at my break because that’s about the time I usually take a break.
I: Where did you go for your break?
F: On that day? Gee, who knows. I was probably out to take a smoke because that’s what I usually do. Wife would kill me if she caught me smoking at home, so my breaks are the only time I can safely sneak a cig. You know how those little women are, they…
I: (Interrupt) Did you see Hector Gonzalez?
F: Gonzalez comes out for a smoke once in awhile, maybe twice a week. Maybe he came out, I just can’t remember for sure back that far.
Which answers are more specific?
Which would help the most in the defense of a fraudulent claim?
A quick interview allows the investigator the ability to establish the merits of a claim and makes everyone’s job much easier.
Keeping everyone involved in the claim in the loop is also a wise way to handle a file. The investigator should keep the adjuster, the defense counsel and the client fully advised on the status of the investigation. Not only is this most efficient and cost effective for the client, it also allows all parties to have input into the investigation.
All information obtained should be validated. This is not limited to the statements and medical reports only; it should also include obtaining a copy of the application for employment and, if applicable, the INS form I9. All information on these forms should be verified; chances are if your claimant turns out to be an illegal alien, the application contains a collection of fraudulent information. Should this be the case, USC 1001 comes into play: False Statements in Writing. And while there’s not a good chance that a US Attorney will take the case on false statements alone, it will add to the cache. Also, in some cases, when an illegal alien is confronted with these issues, the claim may be dropped or the worker will simply disappear from the scene.
In those cases where the claimant is found to be an illegal alien, investigators are cautioned to be very careful when asking questions. While the worker may be here illegally and have no work authorization, he does have civil rights and he definitely knows it. Many illegal aliens have made allegations against investigators and officers because the individuals are aware that INS will not deport them until the allegations are investigated and investigations can go a on for a very long time. This is yet another valuable piece of information that is shared within the community. If you are caught and facing immediate deportation, the best way to put a spoke into the wheel is to allege a civil rights violation. It could potentially delay the deportation for years.
Finally, investigators are well advised to keep in mind the diversity of cultures and language when working cases involving illegal aliens. If any doubt arises as to the ability of the claimant to converse in English, use an interpreter. Not only will this save possible challenges to the case later, but the interpreter can also often supply valuable cultural information that may be helpful in the ongoing investigation.
Tim Bullock is an SIU investigator with Bullock & Associates in St. Joseph, Missouri. He is a former Immigration and Naturalization Special Agent and can be reached at 8163878422.
© Copyright 1997 Alikim Media