Fraud Case Studies

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The Insurance Commission has a zero tolerance approach to fraudulent activities and will pursue those engaged in fraud or attempts to defraud. 

Please report fraud. After all you’re paying for it.

Prosecution is not the Insurance Commission’s yardstick for successfully preventing fraud, but it is a public means of measuring success. The following case studies present examples of successful outcomes of fraud prosecutions.

Falsely declaring inability to work

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Case Study 1

In August 2009, a claimant alleged his wife was driving and at fault during a crash, when at the time, he was the driver and his wife was not in the car. Both were charged with fraud and pleaded guilty halfway through the trial. The couple were both sentenced to a 12 months supervision order and ordered to each pay $1,100 in costs and nearly $2,000 in restitution to the Insurance Commission.

Case Study 2

In May 2011, two people in a vehicle were struck from behind in a car crash while stopped at traffic lights. The driver suffered neck, back and arm injuries and the passenger suffered whiplash.

Despite the vehicle damage being minor, the claimant alleged inability to return to his manual occupation and filed an insurance claim for $433,000 compensation and $342,000 for future economic loss, suggesting he was permanently unable to work in his usual profession as a tiler.

Fraud Investigations revealed through evidence gathering and surveillance the claimant was actively involved in a mobile-blasting business. Investigations found the claimant purchased a towed trailer plant within two days of filing Particulars of Damages and within two weeks registered a business for mobile blasting services. The claimant failed to indicate to the Insurance Commission his intention of engaging in any alternate type of employment and failed to disclose the employment and manual work activities to medical practitioners. Surveillance between 2012 and 2015 captured evidence of the claimant engaging in physical work contrary to his written evidence.

The potential value of the fraudulent claim was $716,000. The Insurance Commission settled the claim for $140,000.

Case Study 3
In April 2001, a tip off from a member of the public led to surveillance to gather evidence about a third party crash claimant suspected of fraud. Over prolonged periods, Fraud Investigations filmed a claimant working as a plasterer. He told the Insurance Commission that he was unable to work and sought of around $500,000. The Insurance Commission made no payment and instead referred criminal charges. The claimant was found guilty of attempted fraud and sentenced to 12 months imprisonment.
Case Study 4

In 2012, a claimant suffered leg injuries after being injured as a pedestrian in a motor vehicle crash. The claimant sought $300,000 in damages, claiming he was unable to work in his usual profession in which he earned $100,000 annually.

Evidence gathered by Fraud Investigations revealed the claimant had not filed a tax return between 2007 and 2012. The claimant alleged a fire destroyed his tax records. Further intelligence found the company the claimant worked for went into liquidation in 2008 and the company director was linked to criminal entities. The 2007 fire did not prevent the claimant collecting financial records after that time or submitting tax returns. The claimant’s salary could not be verified between 2007 and 2012.

The claim settled for $100,000.

Case Study 5
In 2009, a claimant sought approximately $385,000 for loss of earnings after a crash. The claim was based on a fraudulent offer of employment, which after learning that the Insurance Commission was investigating her, reduced her claim to $35,000. The claimant pleaded guilty to attempted fraud and was sentenced to eight months imprisonment, suspended for 12 months.
Case Study 6
In 2010, a third party claimant sought a settlement of $142,000 of which $80,000 was for loss of earning capacity. On 38 occasions of surveillance, Fraud Investigations filmed the claimant attending a workplace during normal working hours, dressed in work-like attire. When questioned, she claimed to be visiting friends. Her employer (and friend) stated that no formal employment was involved, rather the claimant was given flowers and chocolates during visits for any ‘work’ conducted. At trial, she was found guilty of attempted fraud and sentenced to 16 months imprisonment. The Insurance Commission made no payments on the claim.
Case Study 7

In August 2011, the claimant worked as a Traffic Controller Supervisor when he was struck on the legs by a disgruntled motorist who drove into a restricted area. The incident caused injuries to his legs, spine and he later developed post-traumatic stress disorder. The claimant also underwent knee surgery to repair some damage.

The driver was charged and convicted of unlawful assault.

The claimant was unable to return to work and lodged a workers’ compensation claim with his private insurer. He sought $2.4 million in damages for future care from the Insurance Commission.

In 2015, Fraud Investigations gathered surveillance and other evidence observing the claimant moving freely without the aid of another person. The Insurance Commission settled the claim for $300,000 rather than $2.4 million. The matter was referred to Western Australia Police for further investigation.

Case Study 8
In 2012, Fraud Investigations conducted surveillance on a claimant over approximately 12 months and found he regularly worked as a labourer. Further investigation found the claimant was paid for work performed. He maintained he was unable to work in any capacity since his crash, seeking $688,000 in damages. When confronted with surveillance footage, the claimant settled for $70,000, which covered his initial injury and six weeks off work whilst his fracture was healing. Charged with ‘making a false document’, he pleaded guilty and was fined $7,500.
Case Study 9
In 2012, the Insurance Commission financially assisted a claimant after a road crash, as he was allegedly unable to work. A tip off, confirmed by further investigation, found that he continued to work as a courier. At that time, the Insurance Commission paid $25,200 to the claimant, continuing at $1,200 per week. He pleaded guilty to attempted fraud and was sentenced to 12 months imprisonment.
Case Study 10

In December 2004, a 62 year old man was hit by a vehicle while walking with his back to oncoming traffic. Transported by ambulance to hospital, the claimant was treated for injuries to his neck, right shoulder, elbows and buttocks.

The claimant was found to be partly at fault for the accident as he was walking with his back to oncoming traffic. In 2006, the claimant was granted a disability support pension from his personal private insurance policy. Between 2007 and 2008 he received weekly payments from the policy amounting to $53,000.

Fraud Investigations gathered evidence that the claimant was working as a yardman and later as a truck driver while advising the Insurance Commission he was unable to work. The claimant was observed to carry out his duties without any apparent physical restriction.

In 2015, the claimant sought $571,000 in compensation making misleading statements about his physical capacity and frequency of work. Evidence refuting these statements saw the matter settled for $75,000. The matter was referred to Western Australia Police for further investigation.

Case Study 11

Following a motor vehicle crash, an Insurance Commission claimant exaggerated injuries and incapacity to work to obtain a greater financial gain, otherwise not entitled to. The 57-year-old male claimant made three prior motor vehicle crash claims and was identified as the negligent driver in two of those crashes. In February 2012, the claimant was rear-ended at low speed and transported by ambulance to hospital. Sir Charles Gairdner Hospital medics diagnosed him with whiplash.

Via solicitors, the claimant sought $85,000 in damages as a self-employed windscreen repairer working approximately 10 to 15 hours weekly, earning approximately $26,000 annually. He claimed the injuries limited his ability to repetitively bend and lift, prolonged sitting or standing, and working with arms raised above shoulder level.

The claimant denied having worked as a windscreen repairer throughout the Insurance Commission claim management process. He also stated he was unable to remove old windscreens or drive for more than five to 10 minutes.

Fraud Investigations found the claimant’s business advertisement and arranged replacement of a damaged vehicle windscreen. The undercover Investigator recorded the claimant repair the windscreen showing his ability to move in contrast with his claims made to the Insurance Commission and medical reports his practitioners submitted. Video evidence showed the claimant freely walk briskly, bend fully at the waist, bend over the vehicle bonnet, use both arms to pull cables/seals with force, and lift and carry a windscreen using both arms raised above shoulder level.

In light of the evidence, the claim settled for $0. In August 2015, Western Australia Police charged the claimant with attempted fraud carrying a maximum penalty of seven years imprisonment.

Fraudulent workers’ compensation claim

Case Study 12

A claimant working as a clinical nurse at a public WA Hospital lodged a workers’ compensation claim after a workplace injury. Prior to the injury, the claimant was also employed part time at a nursing home.

The claimant received compensation to cover his wages from 2010 to 2012 and top-up payments for his second job. While receiving loss of wages payments from the Insurance Commission, the claimant returned to employment at the nursing home, allegedly defrauding the Insurance Commission by failing to declare his employment.

During medical assessments, the claimant also failed to disclose his work.

A Fraud Investigations enquiry revealed the claimant was overpaid $112,175 in compensation payments. The claimant was charged with Fraud by Western Australia Police and civil recovery action commenced to recover overpayments

Case Study 13

In 2012, the claimant, a prison officer, was struck in his lower back by a large metal object. He reported the incident to his employer but only sought medical treatment a week later due to a gradual increase of pain over that period. The claimant responded well to treatment and was deemed fit to return to work, undertaking modified duties.

In 2013, the claimant’s injury recurred and he submitted a medical certificate to the Insurance Commission from another company. The Insurance Commission nor the employer were aware of the secondary employment.

In 2013, Fraud Investigations conducted surveillance of the claimant participating in a surfing competition despite claiming to be unfit for work due to his recurring back injury. The claimant resigned when presented the evidence. Fraud Investigations referred the matter to the Corruption and Crime Commission due to suspected dishonesty by a public officer and to WorkCover WA to investigate alleged breaches to the Workers Compensation and Injury Management Act 1981.

Provider overbilling the Insurance Commission

Case Study 14
In 2009, a nurse providing care to a catastrophically injured claimant, billed the Insurance Commission for services that were not provided, as did her husband. He was found guilty of eight counts of fraud and fined $1000. The nurse pleaded guilty to fraud charges, was given a two-year intensive supervision order and required to pay back nearly $20,000.

Page Last Updated 09 Mar 2018

Media contact

Kane Blackman
Commission Secretary
+61 8 9264 3556
+61 418 255 549
kane.blackman@icwa.wa.gov.au

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