fraud · 2020-03-10 · confidential what is fraud 3 coming home i drove into the wrong house and...
TRANSCRIPT
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Fraud Conundrum
ICB Annual Conference
Sedick Isaacs
1
4 March 2020
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Contents
Insurance Fraud
• What is Fraud?
• Is SA unique?
• Global Fraud
• Our experience
• Claims Verification Unit
• Fraud Detection
• Collaboration and ICB Benefit
2
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What Is Fraud
3
Coming home I drove into
the wrong house and
collided with a tree I don't
have.
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Claim Payments
4
Check for cover
Policy unpaid
Process Claim Suspected fraud
SIU to investigateMotor / arrange assessment
Check use of vehicleIs panel beater on approved panel
Provide car hire? And ensure vehicle returned asapCheck for previous damage report
Authorise the claim
Rebuild or cash
Cash down payments
Reject claim
Ombud
Payment receivedReconcile cash with claim
Pay clients excessTrigger amendment of Claim Free Group
CFG Not amended at renewalAmend system
Obtain salvage of write offCollect all papers
De-register vehicleIf payment received
Allocate salvage paymentIf payment received
Loss Adjuster
Average
ForensicsFire Claim Quantum
Check for cover
Policy unpaid
Process Claim Suspected fraud
SIU to investigateMotor / arrange assessment
Check use of vehicleIs panel beater on approved panel
Provide car hire? And ensure vehicle returned asapCheck for previous damage report
Authorise the claimMonitor progress and keep client/broker informed
Client signs releaseHand over to TP Recoveries
Contact TP to request paymentNo response from TP
Rebuild or cash
Cash down payments
Service issue
Legal route
Reject claim
Ombud
Payment receivedReconcile cash with claim
Pay clients excessTrigger amendment of Claim Free Group
CFG Not amended at renewalAmend system
Obtain salvage of write offCollect all papers
De-register vehicleIf payment received
Allocate salvage paymentIf payment received
Loss Adjuster
Average
ForensicsFire Claim Quantum
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Motor Insurance
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What Is Insurance Fraud
6
Soft Fraud
Hard Fraud
Inflation Fraud
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Is SA Unique ???
The other car collided
with mine without giving
warning of its intention.
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Is Fraud In South Africa Unique???
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SA R6 – R8 Billion
Est 30% of claims
have fraudUSA $80 Billion
At least $30 Billion
Est Personal
GB Est £2 Billion 10% of losses
estimated to be
fraudulent
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Global Fraud
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Global Type Fraud
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• Phantom Vehicles (UK 8% Est)
• Organised Fraud Rings (UK 15% Est)
• Low Speed Impact (30%+ Est UK)
• False Slip and Fall claims
• False Disability Claims
• False Whiplash Claims / UK
• Medical inflation or non existent claims with providers
• Identity Fraud (14,4m in 2018 US)
• Staged Home Fires
• Staged Road Accidents (UK Est 7%)
• Storm Damage Fraud
• Faked Death Claims
• Cyber crime (Increased criminal opportunity) 2019 - 165m Sensitive Records exposed
• Est losses 2019 $3,5b
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Our Experiences
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Internal Customer Broker
Third Party Syndicate
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Our Experiences
Recovery Clerk provides
his own bank account
for recovery payments.
Internal
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Our Experiences
13
Customer
Cell phone fraud case.
Accident Staging
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Our Experiences
14
Broker
Cell Phone Fraud /
Falsifying Documents
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Our Experiences
15
Third Party
Intercepted email on
Renewal of Broker .
R1.5M
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Our Experiences
16
Syndicate
Paper Vehicle Insured / Stolen
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Bryte Claims Verification Unit
Purpose: Effective Management of Claims Fraud
Claim Investigation
Fraud Analysis
Protect Our Customers
Zero Tolerance
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Claims Verification Unit (CVU) Key Functions
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Provides guidelines to fraud investigation
Evaluate any reports for investigation
justification
Determine the procedures
Investigate Fraudulent claims
Recovery on Fraud Cases
Law enforcement
Protection of customer data
Fraud Education and counter fraud initiatives
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Claims Verification Unit (CVU) Stats
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• Fraud Savings in 2019 amounted to +- R67m
• Targeting 15% return
• By investigating around 8% of all claims
Savings Related To :
• Fictitious Claims
• Misrepresentation
• Non disclosure
• Non existence
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Collaboration with ICB
Vehicle pounds
Education and Training
Sharing of information
Retention of records and access
Checking of red flag clients
Syndicate Identification and Eradication
Panel Beater Syndicates
Collaborate with SAP Direct ICB benefit +_ 50% of Bryte Saving
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Fraud Detection
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Going to work at 7am this morning I
drove out of my driveway straight into a
bus. The bus was 5 minutes early.."
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Data AnalyticsAnalytics
Claims Activity
Criminal Fraud
Cultural Fraud
New Fraud Trends
Analysis
(Data Mining Tools)
Trends
(Quantitative Analysis)
Red Flags
(Employee Training)
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Trend Analysis
Claims
Management
Process
New and
Innovative Claim
Handing Tools.
Predictive
Modelling (Suspicion Score)
Data Analytics
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Finding the right piece???
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Foundational Framework
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Claims Data Analysis
Measurement and Identification Tools
Adding value to customers
File review / MI / Analyse trends
Accuracy of knowing what to look for and being able to quantify the
effect on claims. Recognise and Identify suspicious looking claims
Counter fraud activities should be a protection and benefit for the
vast majority of customers
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Claims Management
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Differentiating among
claims processes that will
easily highlight potential
fraud
Managing the drivers
of customer
satisfaction
Remembering the
majority do not commit
fraud
Strengthening
inspection and loss
adjustment
Capabilities
• Technical skills
development
Fundamentally rethinking the
pathways for resolving claims
to assist with Fraud Mitigation
and elimination
•
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Technology / Analytics / Collaboration