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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

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Claims Against Insurance Companies for Fraud & Bad Faith

 

http://www.pistotniklaw.com/insurance.php

Insurance companies nationwide have begun using claims handling practices that are aimed at cost containment and building claims profit. This means the insurance companies design practices aimed at delaying the payment of claims and underpaying the fair claim value of a given claim. This is not an ethical practice and violates all insurance industry customs and ethical principles of the insurance industry.

Some of the ways that insurance companies defraud claimants and their insured’s are:

In a cross or double insured case the insurance company fails to tell both the claimant and the insured that both individuals are insured by the same company. This presents the insurance company with a conflict of interest that they must disclose. They should but do not always maintain each file in a confidential manner. To the contrary, this special situation provides the insurance company with the ability to defraud both of their insured’s at the same time. By viewing the information in one file and using it against the person with the cross file they can avoid paying out benefits on either side. In effect, both sides are injured by their insurance company’s actions.

Insurance companies ask for a release of information from the claimant or insured so that the person gives up their right to privacy. The insurance company does not tell the person that the information gained that was private and confidential can be used against them. The insurance company does not advise you that they are in an adversarial relationship to you.

The insurance company obtains information about you from “The Index” which is a private database of information on people. Information that is obtained without your consent can be used against you and may or may not be accurate. Many insurance companies also put information into “The Index” about your claim without telling you or obtaining your permission and consent. In the future, information in “The Index” may be used against you for obtaining health insurance, life insurance, auto insurance and otherwise used to harm you.

 

The insurance company adjuster misrepresents information about your claim to you. The insurance company may tell you that you have to go to one of their pro shops to have your car repaired. They defraud you by not telling you that they have a special relationship with the pro shop and receive discounts by sending you to their place of business. The pro shop’s loyalty is not to you. The pro shop’s loyalty is to the insurance company who pays their bills.

The insurance company forces you to go to an independent medical review with a doctor of their choice. They defraud you by failing to tell you that the doctor has a long-standing relationship with you and receives tens of thousands of dollars a year from the insurance company. Some doctors receive hundreds of thousands of dollars for their evaluations on behalf of the insurance company. The loyalty of these doctors is to the insurance company who feeds them.

The insurance company forces you to take used parts on your vehicle for repairs for safety related items. Most insurance companies have claims manuals that do not require used parts for safety related automotive parts.

The insurance company adjuster will not disclose to you the undisclosed conflict of interest they have because of many insurance companies policies that reward the adjuster for keeping you away from a lawyer and settling cases out as low as possible.

The insurance adjuster tells you that you have to accept their determination that you are partially at fault. Most adjusters will try to assign some comparative fault to you, but will not tell you that you have the right to a trial and your day in court. They fail to tell you that you should seek the advice of counsel because their subjective opinion is not admissible in court and a jury or judge may differ with their opinion.

Many insurance companies are using computer software called the Medical Bill Review System (MBRS) to arbitrarily reduce medical bills submitted to them. They do this under the guise that the bills are being reduced as not being usual and customary charges. What they actually are doing is arbitrarily reducing bills by a preset amount that is not actually tied to health care providers in your area. Some states have found this practice unlawful.

 

Many insurance companies are using computer software called Colossus. This is an artificial intelligence computer software package that the adjuster uses to evaluate the claim. The adjuster will not tell you they are using the software to evaluate your claim. The software has built in functions that arbitrarily reduce the value of your claim. The insurance company will not disclose to you that the insurance company has the ability to set the value of a particular claim if given a certain set of factors. In other words, the company can determine how much it will pay for an average claim of a given type. The computer software will provide a limited range of settlement authority to the adjuster.

The insurance company will train its adjusters to look for a preexisting condition in your body to try and say that your claim is not related to the incident in question. They hire medical experts who are trained to and have a proclivity to render opinions that a person’s injuries are not related to an accident, but are instead due to a preexisting medical condition like degenerative disc disease. Since almost everyone who reaches a certain age has a preexisting degenerative disc disease because of normal aging, this allows the insurance company to not pay an otherwise legitimate claim. Many major insurance companies are presently using databases of experts who will testify for the company rendering opinions favoring the company regardless of the true facts.

Insurance companies have begun using mailed documents to try and prevent injured persons from retaining a lawyer. They set up quick contact rules for adjusters to try to reach the injured person within 24 hours after an accident to prevent them from hiring an attorney. What the adjusters don’t tell the recipient of the mailings is that a 1994 study by the Insurance Research Council, found that the average bodily injury claimant would receive 3.7 times more if they hired a lawyer than if they did not hire an attorney. Some of the companies who have used these types of documents are Allstate, CNA, and Liberty Mutual.

Insurance companies have begun developing Special Investigative Units (SIU) that are set up to claim that injured persons and insured’s are defrauding the insurance company. What the insurance companies don’t tell you is that a few large insurance companies realized that in the early 90’s their statistics showed only a 1.5% level of fraud in America against insurance companies. These companies formed the National Insurance Crime Bureau and the Insurance Research Council. Each insurance company has a member of the Board of Directors of the insurance company seated on these non-profit agencies. Even though they claim public service the Insurance Research Council and the National Insurance Crime Bureau are alter egos of this select group of top insurance companies. They attempt to provide information to the public under the guise of a not for profit public agency. In reality they are developing information that the insurance industry can use to reduce claims and build premiums. The goal of SIU departments is to increase alleged fraud claims against their insured’s and claimants to the level of 10%. They measure the money that is not paid out because of false SIU claims that people are fraudulent. This is one of the largest fraudulent schemes to build insurance company profits that have ever been developed. This is unfortunate for the people who are targeted by the SIU departments. A person can be targeted just because they have a motor vehicle accident and have less than $1,000 of property damage or because they have a soft tissue injury. Neither of these factors provides any basis for the insurance company to claim fraud. One insurance company using this tactic is saving in excess of two billion dollars a year on claims.

Insurance companies exploit the people who trust their adjusters. By establishing quick contact rules with insurance company management monitoring the adjuster’s performance in keeping injured people from attorneys, they can effectively eliminate over 80% of all claims from becoming attorney represented. What they don’t tell you is that the adjusters are being given bonuses, vacations, gift certificates and employee performance evaluations based upon how fast they contact injured people and how many they lose to lawyers.