Category Archives: Insurance Fraud

Florida Still a Top 10 State in Vehicle Thefts Despite Dramatic Decreases Overall

The good news—the probability of your car being stolen has been dwindling over the past two decades. The bad news—if you live, work or play in Florida, your chances are still higher than in 47 other states.

That assessment is supported by the National Insurance Crime Bureau (NICB), which recently released a national analysis of vehicle theft since 1960.

This report, which compared annual statistics for thefts, population, and vehicle registrations from 1960 through 2013, found that even with an increase in population and registrations of over 60 million in 2013, thefts were down to 699,594. Based on the most recent FBI crime figures, these numbers translate to a whopping 58 percent reduction in the number of vehicles stolen last year from 1991, when vehicle theft reached an all-time high of 1,661,738.

Florida has historically been a state with a high level of vehicle theft. From the years 2000-2013, Florida ranked third in the number of stolen vehicles nationwide, surpassed only by Texas and California. There have only been a few years (1963 and 1966-69) when Florida did not rank in the Top 10.

The NICB attributes a variety of factors which together have brought about such positive national results, including:

  • Law enforcement efforts to develop innovative investigative processes
  • The sharing of these processes across law enforcement communities as well as with the International Association of Auto Theft Investigators and the International Association of Special Investigative Units
  • Collaboration and coordination among these agencies
  • New technologies incorporated into vehicles during the auto manufacturing process
  • New technologies available to purchase in the after market

Click on the link to read the NICB national analysis of vehicle theft.

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Filed under Insurance Fraud

Staged Accident Recruiter from Palm Beach County Sentenced to Nine Years

A West Palm Beach man, who participated in an $8 million insurance fraud scam, was recently sentenced to nine years in prison for his role in the matter.

Joel Antonio Simon Ramirez, about whom we reported on our FL PIP Guide in April, helped recruit individuals to participate in staged automobile crashes. According to a story in the Palm Beach Post, the 30-year old worked together with three other chiropractors who filed fake insurance claims for the participants in these crashes. They operated the scheme out of clinics throughout Palm Beach County.

Following a six-week trial in April, all four defendants were found guilty of money laundering and mail fraud. Ramirez was also found guilty of helping stage the auto accidents.

By violating PIP insurance provisions, these schemes not only cost insurers but also hurt Florida drivers, federal prosecutors said. The conspiracy was part of a larger staged accident ring dubbed “Operation Sledgehammer” by investigators who discovered that many participants damaged vehicles using sledgehammers to give the appearance of a crash.

Nearly 60 people have been charged in federal court and almost 40 have been charged in state court as part of this sweeping investigation. Most have pleaded guilty to participating in staged accidents and then seeking treatment for bogus injuries. According to prosecutors, the five ringleaders fled to Cuba.

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Filed under Fla. Stat. 627.736 (2008), Insurance Fraud

SIUs Detect Soft Fraud with Technology

Unlike the criminals guilty of ‘hard’ fraud—such as the ones we often report about on our blog involving PIP insurance schemes through staged car accidents—there is another group of people who commit ‘soft’ fraud without fully realizing the impact it has on increasing their insurance costs.

Soft fraud, also known as opportunity fraud, is the bane of the insurance industry and the Special Investigative Units (SIUs) that serve them. The little lies, exaggerations, and exclusions that make up this type of fraud are difficult to detect, and when they are uncovered, are often difficult to investigate without offending long-term customers.

According to a commentary by Joseph Bracken on InformationWeek Insurance & Technology, soft fraud includes circumstances like:

  • Overstating the extent or origin of damage when filing a claim
  • Overestimating the value
  • Minimizing annual mileage driven
  • Neglecting to mention the existence of teenage drivers

Consumers’ tolerance to soft fraud has been shown in an Insurance Research Council 2013 study in which 24 percent of respondents thought it was acceptable to overstate the amount of a claim submission as a way to offset the cost of a deductible, and 10 percent said that insurance fraud “doesn’t hurt anyone.”

However, the Coalition Against Insurance Fraud, reveals just how much insurance fraud hurts—it costs the economy $80 billion annually, which is enough to cover salaries of 2.2 million American workers for a year.

This is where analysis using technology can come into play, Bracken says, to help SIUs protect policyholders from soft fraud, including the following:

  1. Establish a baseline on the number of claims being investigated, keeping in mind that based on industry data, about 10-20% of insurance claims have the potential to be fraudulent.
  2. Establish patterns of activity according to type of claim or claimant demographic to identify inconsistencies.
  3. Set up business rules and maximum limits to identify the claims that need closer review, basing them on claim characteristics (exceeding a certain dollar limit) or insured behavior (such as a change in the coverage limit up to 60 days before a claim).
  4. Develop norms for common claims and flag those that veer from the norm.
  5. Compare in-house and third-party data to identify inconsistent behavior.
  6. Compare average retail store values with claim values.
  7. Eliminate data silos so investigators can merge data from different sources within the company.

While this analytical investigative approach may seem a heavy-handed way to combat soft fraud, it ends up being an essential component to achieving several goals—it’s successful in detecting claims that are most likely to be fraudulent, it’s cost-effective for SIU investigators to zero in on those claims, and it ultimately decreases premium costs.

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Filed under Insurance Fraud

Will Florida’s Reported Drop in PIP Fraud Continue?

Florida, one of 12 states with no-fault auto insurance, has reported its fair share of insurance fraud, mostly through scams involving Personal Injury Protection. PIP insurance provides personal injury protection up to $10,000 in immediate medical coverage without having to establish fault in the court system.

As industry insiders know, this monetary level is often seen as an easy target by fraudsters. Even though PIP premiums have represented only about 2 percent of all of Florida’s collected insurance premiums, they account for nearly half of all auto insurance fraud referrals, the Florida Office of Insurance Regulation (FOIR) has established.

But all of that may be changing, the National Insurance Crime Bureau believes, as auto insurance fraud has actually dropped in Florida since a 2012 law reformed PIP. As we posted on our FL PIP Guide this past March, tighter legislation, enhanced public awareness, and coordinated law enforcement efforts appear to be having a positive effect on PIP fraud in Florida.

These changes specifically include stronger penalties for medical providers who commit PIP fraud, a 14-day window for accident victims to seek medical treatment, and reduced benefits and treatments.

In line with projections made when HB119 was passed, FOIR expects PIP coverage rates to decrease by an average of 13.2 percent, reducing auto insurance rates 1.2 percent overall, according to figures based on a review of data from 20 insurers that provide auto insurance to more than 75 percent of the Florida market.

However, because PIP coverage savings will still be relatively small in comparison to the overall total cost of a typical auto insurance policy, and because fraud is at times difficult to detect, the next few years may be a better indication of whether these changes have produced a statistical blip in the numbers or a longer-term trend.

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Filed under Fla. Stat. 627.736 (2012), Insurance Fraud

Broward Staged Accident Results in Five PIP Fraud Arrests

Five individuals were recently arrested for their involvement in an alleged staged accident that took place in Broward in July 2012, according to an announcement by Florida Chief Financial Officer Jeff Atwater.

The five, who were arrested on grand theft and insurance fraud charges, carried out the alleged scam which resulted in fraudulent Personal Injury Protection (PIP) claims costing almost $40,000. Officials say a sixth individual is associated with the crime as well but has yet to be apprehended.

Investigators with the Department of Financial Services’ Division of Insurance Fraud (DIF) said that the five participated in the alleged crash as vehicle passengers. Shortly after the accident, they sought medical treatment at several South Florida clinics for bogus injuries. GEICO, Ocean Harbor and Gainsco insurance companies received fraudulent PIP claims as a result of the scam.

Those arrested include: Alfredo Romero, 66, of Hollywood; Alice Martinez, 27, of Pembroke Pines; and Jose Rodas, 33, Whitney Lopez, 25, and Mirna Madrid, 37, all of Fort Lauderdale. Alfredo Romero was also arrested in July 2014 for his role in another Broward County staged accident.

The cases will be prosecuted by the Broward State Attorney’s Office.

Mario Ruiz, 32, of Fort Lauderdale is the sixth individual currently wanted in connection with this crime. Anyone with information regarding his whereabouts is asked to contact DIF at 1-800-378-0445 or the Broward County Sheriff’s Office. Citizens may remain anonymous.

The Department of Financial Services to date has awarded almost $349,000 to nearly 60 citizens as part of its Anti-Fraud Reward Program. The program rewards individuals up to $25,000 for information that directly leads to an arrest and conviction in an insurance fraud scheme.

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Filed under Fla. Stat. 627.736 (2008), Insurance Fraud

Miami D & J Rehabilitation Center Target of Another DIF Fraud Arrest

Yalily Clavero Ruiz is the latest to be arrested by the Florida Division of Insurance Fraud (DIF) in connection with deceptive activities at D & J Rehabilitation Center, a Miami clinic that was incorporated in 2009. According to DIF, the 34-year old manager is charged with insurance fraud, grand theft and organized scheme to defraud.

Clavero Ruiz allegedly instructed patients, many of whom were staged accident participants, to sign for treatment that was not provided to them. In one instance, video surveillance conducted on behalf of State Farm showed that Clavero Ruiz paid $1,000 to a patient, who did not receive any treatment, to sign off as if treatment was provided.

DIF has made numerous arrests this year tied to staged accidents and participants who were referred to D & J Rehabilitation.

In October, our FL PIP Guide reported on two recently arrested in the scheme—Victor Manuel Hernandez and Vladimir Caro—whose involvement caused hundreds-of-thousands in fraudulent billings to be submitted to insurance companies.

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Filed under Insurance Fraud

Owner of ‘Exclusive Health Systems’ Clinic Arrested on Insurance Fraud Charges

Marlene Lopez del Castillo was arrested in October in connection with an illegal insurance scheme, according to the Division of Insurance Fraud (DIF). She allegedly pretended to be the doctor at Exclusive Health Systems, a Miami clinic she owned. Lopez del Castillo, 44, was charged with insurance fraud, grand theft, and practicing medicine without a license.

According to DIF, two people who participated in a staged vehicle accident in October 2011 visited Exclusive Health Systems for initial evaluations. Lopez del Castillo allegedly behaved as if she were the physician on call and examined both patients during their clinic visits, even though she is not a medical doctor nor does she hold a license with the Department of Health.

Lopez del Castillo also allegedly fabricated follow-up examinations that were later signed off by Dr. Hugo Goldstraj. Dr. Goldstraj gave a statement to investigators indicating that Lopez del Castillo prepared the reports. He said that he did not actually examine the patients nor do the paperwork.

Dr. Goldstraj was arrested in 2013 by DIF in a separate investigation, dubbed ‘Operation No Med Service,’ that involved a massive false billing scheme. Dr. Goldstraj was convicted in May and has since surrendered his license.

Lopez del Castillo opened Exclusive Health Systems in 2000.

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Filed under Insurance Fraud