WHAT EVERY INSURANCE PI SHOULD KNOW
ABOUT WHAT CLAIMANTS ARE TOLD BY A DISABILITY CLAIMS REPRESENTITIVE
UNDERSTANDING SURVEILLANCE and INVASION of PRIVACY
What is a Disability Claims Representative? They are insurance industry providers who provide claimants with information and knowledge about their disability claim and the claims process. They fell that it is their duty to provide the claimant information at least equal to that being used by the insurance companies in making liability decisions on their, the claimant's or injured worker's claims.
In addition, a Disability Claims Representative believe claimant/injured workers have the right to a fair, objective and honest review of each of their request for benefits and should be paid in accordance with the conditions set forth in the insurance contract between the claimant/injured workers, the claimant’s employer, and the disability insurer.
Most also are motivated a belief that all disability Insurance Companies, Third Party Administrators and like providers of injury or disability benefits should be held accountable for any strategies and unjust claims practices used to deny benefits for a profit. This is not to deny that all claims should be processed according to statute and protocols set out by state and industry standards, this is to say that valid and fraudulent claims are treated the same by many of these providers.
Many claimant/injured worker's often asked their attorney and their Disability Claims Representative, if they have one, if disability insurance companies and similar entities have the right to conduct surveillance on a claimant in order to obtain visual documented evidence of what is called in the industry as an “inconsistency of report”. The answer to this question is a resounding, “Yes they do.” Since disabled claimant/injured worker's are entitled to monthly benefits based on a “condition” of contract there is, of course, no expectation of privacy protection from surveillance. In fact, to my knowledge as a surveillance investigator for many years, the courts (both workers’ comp and disability) have upheld the right of an insurance company, third party administrator and other similar entities to conduct surveillance in order to fully investigate and reveal the credibility of claims presented to them for payment by claimant/injured worker's.
Many claimant/injured workers call and confront their adjuster/examiner about noticing what they believe to be a private investigators hiding covertly (if they are how does the claimant know?) in the neighborhood for about two to three days. Many times a good adjuster will respond, “I am not aware of surveillance being conducted on your claim.”, then immediately call the investigator in the field and advise the investigator that he or she has been “burned” (revealed) by the claimant/injured worker. Even with this said the claimant/injured worker will remain absolutely convinced that they are being watched even if their claim is a legitimate one. Remember that 4 out of 5 claims are fraudulent in some way.
Disability insurance providers are not know for freely tossing funds about and if it were known are held stringently to an approved spending plan on every claim. The budget dollars spent on the investigation of a disability claim is normally proportional to the expected financial reserve profit the company receives if the claim is denied. Three-day tag surveillance costs the insurance company $1,200 - $3,000. Third party reinsurers often hire cheaper less experienced private investigators so their costs per claim are significantly lower, roughly in the neighborhood of $900-$1,200, yet the quality of the work product is less than WCAB standard.
Therefore, disability insurers will not pay for surveillance unless they know that they are going to be assigned liability for the claim. I can tell you that under it is only unique circumstances that surveillance is assigned unless a claim has already been approved for a loss payment. It is almost never done proactively let alone aggressively. If there is no future liability to pay the claim, why toss money out on surveillance? It’s just money thrown out the window if the claim can be denied for other valid reasons. Even though there is a third and impartial witness to the facts of the claim refuting the claims of the claimant/injured worker.
During my many hours of insurance covert surveillance and 100's of insurance cases I have had occasion to speak with many claims experts, examiners and adjusters and many will tell you that many of their surveillance referrals were the result of a phone call which they received from an employer, a neighbor, a friend, or a relative who informed them that the claimant/injured worker was not being honest about their claim and in fact was engaging in physical activity well beyond the claimant/injured worker's stated restriction levels. One of my most called upon adjusters said that on one claim she was working that the claimant/injured worker's employer called her to report that the claimant/injured worker had been seen by a co-worker loading 10 sheets of plywood into his truck at a local Lowe's building material store while still out of work on a total disability due to a right shoulder injury. I have to tell you, the entire neighborhood, family and friends know that these folks are not working and getting paid and that doesn’t set well with them. A claimant/injured worker really never know who may be watching and who will pull the trigger to have them watched.
From a disability insurer’s perspective, the purpose of surveillance is to obtain written documentation which clearly verifies the claimant/injured worker (and/or their doctor) is reporting restrictions and limitations precluding a specific or all work capacity which are “inconsistent” with the claimant/injured worker's actual physical activity level in order to collect monetarily on the claim.
I’ve have read in many insurance disability claims newsletter and periodicals that as much as 15 percent of all claims presented for payment are in fact fraudulent, with some reporting even higher percentages. I have seen claims where the claimant/injured worker have been on the "DOLE", claim (that will date me) for several years due to the dropping of the investigative ball. In this case a family member called the adjuster and reported the claimant/injured worker, and the information was so good that the adjuster referred the claim out for surveillance for a period of 10 days. And low and behold the claimant was observed “water skiing” one weekend and the other he went "river rafting". Both very physical sports.
Most claimant/injured worker's caught by insurance surveillance always use the "Good Day Defense", stating, "Yes, I was mowing my lawn and building a cinder block retaining wall on that day, but I was in bed for a two week after that in intense pain” excuse which is a questionable and inadequate defense for their observed and documented physical activity level. It never holds up! Hang on here I am going to reveal what I have seen work.
Unfortunately these Disability Claims Representatives, instruct claimant/injured workers that surveillance is a probable reality for every claimant/injured worker who is receiving benefits from an insurance company for an injury. While the claimant/injured worker has no expectation of privacy while in the process of a claim, there are many ways in which insurance “surveillance” can be managed thereby preventing the insurance company from using it to document the denial of any claim even a fraudulent one.
I am hoping in this issue of "A Day in the Life of a PI" to clear up some of the many questions I have received from surveillance PIs all over the nation on the issue. I hope this blog issue helps you come to the point in your investigations where you realize that a Disability Claims Representative is involved or may be guiding and directing the claimant/injured workers you are currently working, those you work in the future and helps you realize some of the cases in the past which were grossly effected by a Disability Claims Representative’s involvement in some way.
During Activities Check
A Disability Claims Representative will inform the claimant/injured worker that his or her disability insurer may have a private investigator go out and interview their neighbors, coworkers, friends and sometimes family. The Disability Claims Representatives will even go as far as to suggest what the investigator might ask their neighbors such as asking them to describe the claimant/injured worker’s physical activities, comings and goings to their homes, if they have seen visitors at the claimant/injured worker’s home, and any other possibly observed activities taking place on the claimant/injured worker’s property, like interaction with their children, their taking out of the trash, gardening and other routine-type tasks. The claimant/injured worker are cued up as to everything you might do as an investigator to reveal their criminal activity in a fraudulent claim. These Disability Claims Representatives will instruct claimant/injured worker to visit their neighbors where possible and ask their neighbors and friends to call them if anyone shows up on their door step asking questions about them and their activities. In my opinion, in a claim where the claimant/injured worker is found to be guilty of insurance fraud and a Disability Claims Representatives is found to have been involved in their claim and coaching them, the Disability Claims Representatives should be charged as a co-conspirator in committing insurance fraud.
DCR’s Instruction in Managing Surveillance and Blowing the PI’s Cover
In this situation the Disability Claims Representatives – DCR instructs the claimant/injured worker about the concepts of insurance surveillance and that surveillance is based on the fact that representatives (PIs) from an insurance company actually watch them engaging in physical activity when they are not aware that they’re watching. In other words, the success of any surveillance record is that it remains covert, secret and unnoticed. The claimant/injured workers are instructed that surveillance loses its value if they as the claimant/injured worker are AWARE that they are being watched.
The DCR then embarks on teaching the techniques to claimant/injured worker which will be used to become aware of the PI’s presence. The claimant/injured worker is then instructed how to “manage” surveillance and “blow the PI’s cover”. They are instructed by the DCR to let the PI know that they know that they are present. Once you do this, the surveillance is over – they are BUSTED! Other wised know in the profession as being “BURNED”. Everyone then goes home and the claimant/injured worker is free to carry out the fraud another day. As one of my PI colleagues once said, “Only if a claimant/injured worker identifies you three times, you’re truly burned”. I have had cases where claimants actually “play to the cameras” when they identify a surveillance team, but I don’t recommend that. Honesty works, not drama. Although, some claimant/injured workers are truly worthy of an Emmy Award!
They are taught several ways to “blow the cover” of a surveillance investigator. They are told that they actually approach the surveillance vehicle and let the PI know that they have identified them, or they can call the local police and ask them to remove the vehicle watching their residence from the area. We all know that if we are parked on the street legally there is nothing the police can do to remove us, RIGHT! They are further instructed that at anytime if they are placed in a situation of fear, it is strongly recommend that they call the police and request them to ask the investigators to leave. What real cop is going to do that if your presence is explained. I always ask the contacting officer not to give up my identity as the person being watched has ties to the local police agency. They get it! This may get a little sticky if you have another cop, city administrator, city or State employee under surveillance.
Some, including the police are under a mistaken self imposed rule that surveillance investigators are supposed to inform the local police of their presence when they are in a city and claimant/injured worker are told they must do that if they are watching them at or near their homes. The claimant/injured worker is told however that most surveillance investigators don’t follow the rules (is this a rule or a law, neither). They are also told not to expect a professional private investigator to tell you the truth, in fact they are told that most investigators will tell them and/or their neighbors anything they think will be believed to get the information they want. Claimant/injured worker are told by DCRs that most surveillance teams use bogus plates on their vehicles so their agency can’t be traced. Is this true??? NOT! I use them all the time so I don’t have cockroaches and friends of police officers following me home, it’s a matter of personal safety. Do you mean to tell me that a police officer would risk his or her job to run a plate sitting out in front of a family or friends residence knowing that it is against the law and department policy to do so, YES that is what I am telling you!
The claimant/injured worker is tutored by the DCR that private surveillance teams are required to follow the laws of the state they are working in, but that they rarely do. They are also told the following;
Surveillance PIs must ask permission to surveil you from your neighbor’s property.
Surveillance PIs must be licensed in your state as a private investigator.
Surveillance PIs are prohibited from breaking any laws while engaging in surveillance activity.
The claimant/injured worker is told by the DCR that the best way to stop an insurance surveillance investigator is to blow his or her cover and let them know YOU (the claimant/injured worker) are watching THEM. Then, EVFERYONE goes home.
The DCR will also infasize to the claimant/injured worker that at anytime they become fearful or can act fearful to the police because they have identified a surveillance team in their area, they blow the investigator’s cover and the police will send them on their way. Now we know that not at all true. The combined goal here is to continue the fraudulent activity and in turn, cause insurance companies to wasted claim allocated funds!
PRIVATE INVESTIGATOR MISTAKES
DCRs are quick to inform a claimant/injured worker in a personal way not to comply with their insurance providers requests. One DCR put it this way, “Private investigators actually make a lot of mistakes following the wrong people. One of my client’s daughters was surveilled by The Hartford for several days. Field representatives are required to take the claimant’s picture so he/she cannot be misidentified in any future surveillance. Now you know why your disability insurer asked for a copy of your picture driver’s license for the claim file. Sneaky aren’t they?
The DCR then goes on to tell the claimant/injured worker, How To Recognize Insurance Surveillance.
1. If you are being asked to submit to an IME. Great chance for tag surveillance. (3-day)
2. If you see a strange car in the neighborhood or unidentified car showing up more than once in 24 hours. Or, strange car following you on the road, or circling the street in front of your house. It will be a surveillance team.
3. If you see the same person sitting in your doctor’s reception room, which you later identify as following you in a car, or into a public place. It will be a surveillance team member.
4. If you receive odd phone calls about delivering a package to you at another location or calls from vendors you don’t know asking where you will be at certain times of the day. It will be a surveillance team member.
5. If you see a person walking in front of your house with a camera or video recorder. Likewise, person clearly taking pictures of your home or car. It will be a surveillance team member
6. If you are experiencing problems with your neighbors and others who have threatened to report you to the insurance company. They have been influenced by a surveillance team member.
7. If your doctor tells you someone came by and requested a copy of your medical records. It was a surveillance team member.
8. If your insurance field representative asks you if he/she can take a picture of you and your house. Surveillance is about to be scheduled.
9. If your Insurance company calls you out of the blue for a long “TPC” (telephone interview). These calls always take place just before surveillance because the representative is trying to catch you in a lie. All are precursors to surveillance activity.
10. I must tell you (DCR speaking) about “Arbitrary and capricious” behavior on the part of the insurer. This is when your Insurance company suddenly begins to manage your claim in other directions and makes frequent requests for information and other items which don’t seem proper.
Adversarial Surveillance Prevention – The Importance of Your Physician Treatment Plan
The DCR will then also discuss the claimant/injured worker treatment plan and present their rights and protection under that plan. As mentioned earlier the DCR will tell the claimant/injured worker that they do not have specific privacy protections from insurance surveillance, but there are actions which can be taken by the insured to prevent the use of surveillance as credible documentation in support of a claim denial. They tell the claimant/injured worker emphatically that disability claims cannot be denied solely on the basis of surveillance. They tell the claimant/injured worker that surveillance is normally requested by the insurer to bolster otherwise weak documentation in support of a claim for denial and that surveillance is only one of many “risk management tools” used by the disability insurer to document proof of “inconsistency of report”. They tell them that this means that the insurance company actually sees you performing physical activity greater than you and/or your physician previously reported and that surveillance is just “one piece” of documentation among others which eventually lends to the allegation the insured “does not meet the definition of total disability” in the policy.
The DCR then advised the claimant/injured worker that the best way to support a disability claim and prevent the misuse of surveillance data by having their doctor clearly document a “medical treatment plan” to be written by primary treatment physicians, which will support certain levels of physical activity. The DCR will even give the claimant/injured worker examples to use,
If the claimant/injured worker suffers from fibromyalgia the claimant/injured worker should ask their doctor to recommended that they to engage in daily exercise and physical activity as is desirable when the claimant/injured worker is able.
The DCR also gives these directions for many impairments including diabetes. In fact, DISABILITY CLAIMS REPRESENTATIVE recommends to diabetic claimant/injured worker that they obtain an actual prescription for daily exercise from their physician as part of a formal treatment plan for the disability.
The point here is that all claimant/injured workers receiving disability benefits from an insurance company should discuss and obtain a written treatment plan from their primary care physician clearly documenting various levels of physical activity which they want to be able to perform.
The DCR will go on to tell the claimant/injured worker what an appropriate treatment plans usually states and how it should be stated. It should sound like this (DCR speaking), “Patient is to be seen for bi-weekly consultation and medication management in combination with 10-15 minutes of daily walking, or other physical activity as is able depending on varying levels of fatigue and joint pain.” (Fibromyalgia patient)
Here the DCR states how the plan BEATS the system, “This treatment plan, written by Disability Claims Representative for a Rheumatologist does not give the patient work capacity, but does recommend up to 15 minutes of walking, if possible. If this patient is subsequently observed walking for up to 15 minutes a day, the surveillance is useless since the observed activity is allowed within the treatment plan documented by the physician. In other words, the insurance company should already know, through the treatment notes, that physical activity is allowed because of the treatment plan provided by the primary care physician.
The DCR will stress to the claimant/injured worker that once the insured has been given a clear, specific treatment plan by their physician he/she should never be observed engaging in physical activity greater than that certified by the treating physician.
One DCR was overheard as he spoke to claimant/injured workers and attorneys to say, “I am well aware that claimants (and regrettably, their attorneys) attempt to defend observed levels of physical activity with the adage, “Yes, I went to the Mall with my friends and walked around for 4 hours, but I was in bed for a week after.” I know there are differing opinions about this, but one disability claims provider said, “Here we do not defend surveillance activity with comments characterized with the stereotype “I have good days, and I have bad days” (known as the GOOD DAY/BAD DAY DEFENSE). This type of defense is relatively useless since normal, healthy people who over exert themselves will, no doubt, suffer for a few days afterward. For example, if I usually walk 2 miles a day on my treadmill and then walk 5 miles, I’m going to be sore for a week. It’s a fact that healthy, normal people who engage in physical activity greater than they are used to will also “suffer” for the efforts. It is therefore presumed a disabled person will also be affected by overexertion – because that happens to everyone.
He went on to say, that exercise is as important to a diabetic as the insulin or glucophage taken daily. Therefore, ask the physician to actually document the need for exercise and activity by writing a prescription as part of your formal treatment plan. This could also be true for claimants with failed back surgeries, MS, fibromyalgia, and depression. If the doctor includes a 20 minute work-out at a gym twice a week, or swimming, or any other reasonable activity, it should be documented in the office consultation notes as part of the physician’s treatment plan and goals. Treatment plans should not recommend physical activity which could be interpreted by the insurance company as work capacity (how to beat the system instruction), but if the physician documents exercise as part of his/her treatment plan, any surveillance observing the same level of activity cannot be used against you to deny your claim.
The DCR will clearly express that the BOTTOM LINE is, whatever it is you are telling your insurance company you cannot do on the monthly Claimant Statements, you should not be seen doing. So have your doctor say that you can do as a part of your treatment plan the things you want to be able to do. The DCR will instruct the claimant/injured worker that most disability insurers will send the surveillance DVD to all of the claimant/injured worker’s primary care physicians and ask them to comment. A physician who has been documenting a limitation of “patient is unable to walk > 10-15 minutes” who later sees the same patient walking for hours on a number of surveillance DVDs will most likely drop that patient like a hot potato. And he should, or be caught up in fraudulent activity. The DCR will further instruct the claimant/injured worker that the best way to manage a disability claim is to discuss your allowed and desired activity with your physicians and ask them to document it in the consultation notes.
A good DCR will the speak to the issue of having common sense to the claimant/injured worker advising them to use common sense when completing all paperwork and when making statements. The claimant/injured worker is reminded that if they recently wrote on their Claimant Statement that they never visit the place of their former business, they should not be going there! They are told that if they used to work at home, but don’t anymore, then take down the business sign hanging on the front of their house and change your voice message to a personal one, remove that, “Hello, you’ve reached Charley’s Auto Repair Center.” The claimant/injured worker is told that using common sense can save the claimant/injured worker an unwanted visit from the surveillance team or their insurance company’s field representative. The DCR will express to the claimant/injured worker that they can manage their claim by talking with their physicians about their allowed, required and desired activity and to “stay in control” of the process of what is being reported to the insurance company and what is not.
One DCR made this statement about surveillance, “In reality, surveillance is the least effective “risk management” tool because not all impairments can or should be observable. For example, I’ve often wondered why insurance companies spend their “risk” dollars surveilling depression claims when nearly all therapists recommend daily exercise and varying levels of activity for that group (We all know it’s to document social interaction which is a clear sign of the lack of depression). Although disability insurers usually go for “the biggest bang for the buck”, surveillance, like the definition of disability, requires a stretch of the viewer’s imagination to support most claim denials. Dollars spend on IMEs probably result in twice as many claim denials as surveillance. Despite this, I remember a time when (name redacted) required surveillance for all fibromyalgia claims. Clearly, it must have been profitable for the company to do that.
The truth is insurance surveillance causes disabled persons to feel worse about themselves, and their impairment than they already do. Surveillance IS an invasion of privacy, and can have significant emotional effects on those who depend on their financial support from disability insurers who are also doing everything they can to NOT pay claims. Wow, now that was a stretch to cover fraud! No one I mean no one with a legit claim needs to worry about these issues. If you are sick or injured, that’s what insurance is for. It’s the abuse that is frowned upon!
The DCR goes on to just dramatize the impact of surveillance on claimant/injured worker stressing that the claimant/injured worker reactions to insurance surveillance can be overwhelming fear-induced stress, anger – “How dare they follow me to the Mall!”, paranoia, tearfulness, hopelessness, and an intense feeling of not being in control of
one’s life, family or finances. One client asked me recently, “Does the insurance company know how terrible surveillance makes me feel?” Unfortunately, they do know, but in their world how a claimant feels about spying and invasions of privacy is not relevant to any claims decision. I must say at this point that DCR should write a book, “How to Steal by Deceit and Manipulation of the TRUTH!”
As the DCR winds down their instruction and countermeasure tactics the inform the claimant/injured worker that Insurance companies will tell them that surveillance is imperative to the identification of fraudulent claim and even admit that this is particularly true of Workers’ Compensation claims which seem to encompass a more broad spectrum of the middle class population with 4 out of 5 being fraudulent in some way. Nevertheless, the DRC tells them that it is unfortunate that so many honest claimant/injured worker’s claims are denied in the process due to surveillance.
The DCRs closing instruction to the claimant/injured worker;
Remember this:
1) You should have frank and open discussions with primary care physicians about including levels of activity and exercise into their consultations notes and medical treatment plan;
2) Use common sense concerning what you report to the insurance company about your activities; and
3) Blow the cover of any surveillance investigator if you suspect one.
Now you know what a Disability Claims Representative is and what they do!
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