Fraud Chronicles 11: Home Run King Strikes Out

Insurance fraud is a crime that hurts everyone. When someone makes an insurance claim that is false and it is not detected, the cost of that claim becomes part of the cost of insurance and so raises everyone’s insurance premiums for auto, homeowners, Workers Comp, and other lines of insurance.

When a case looks suspicious, containing “red flag” indicators of possible fraud, an investigator is often brought in to find out the true facts of the case. DMA Claims Services investigates suspicious cases, conducts surveillance, and if an insurance claim is found to be fraudulent, turns the information over to the insurance company.

This is a case from the DMA Investigations archives, Part 11 of the Fraud Chronicles, involving a case where the person claiming to be disabled was found to be engaging in various strenuous recreational activities.

Home Run King Strikes Out
By Jim Smith, Deputy Director of Investigations

“The subject we were hired to investigate had numerous subjective back-related complaints, supposedly the result of a fall from a loading dock. The injuries could not be verified by medical exam and he had been released back to work under modified duties (lifting restricted to 10 pounds, restricted bending and twisting).

“The subject continued to report to work but was regularly leaving early complaining of pain. The subject’s general appearance (big, strong, apparently healthy) and the subjective nature of the complaints were the “red flags” that triggered bringing in an investigator.

“The first day out on surveillance went nowhere as the subject was inactive. We returned on a weekend day and within a few hours our investigator hit the jackpot. After tailing the subject to the laundromat (no problems in handling the laundry) and a picnic (no problems with the cooler), we arrived at a park where a softball game was in progress.

“Our man changed from sandals to cleats and took the second base position where he aggressively fielded ground balls, throwing runners out. He then came up to the plate, hit a monster home run over the fence and circled the bases triumphantly. His skill and physical ability had so impressed the opposing team that he was walked intentionally when next at bat. We got film and re-verified identity.

“One would have thought that the softball exploits would have been enough, but apparently our subject started making legal noises. We were asked for more film.

“This time he took us to the beach along with his family. No problems carrying the cooler and other items to the sand, and no problems body surfing for nearly an hour. Two more hours of teaching his kids how to body surf (lifting them in the water, catching them in the waves) didn’t present any problem either. More good film showing that the complaints of pain were truly subjective (more like an extreme allergy to work).

“As the examiner suspected, the subject sued. Our investigator was subpoenaed to appear before the Workers’ Compensation Appeals Board to introduce the surveillance video. Various delays ensued and before any testimony was required, the subject’s civil suit was dismissed due to a criminal conviction of the subject on insurance fraud.

“There was no joy in Mudville. The home run king had struck out.”

But for the rest of us, another victory for truth, justice and lower insurance premiums.

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