Concern: Fraudulent Claimant
A leading third-party administrator to employers and insurance companies was struggling with a particularly troublesome claimant. Claiming a low back injury, the subject’s claim threatened to cost the administrator upwards of six figures in monetary loss. Sensing fraud, this administrator enlisted Ethos Risk Services to uncover contrary evidence to the claimant’s injury.
1. Ethos opened this case with an Internet Mining Investigation designed to uncover data through a series of web searches including social media sites. It was learned that the claimant had an interest in motorcycles.
2. Armed with knowledge of the claimant’s hobby, Ethos initiated surveillance at the claimant’s residence and obtained documentation of the claimant traveling to a restaurant with family and friends.
3. Further surveillance efforts were initiated and true to form, the claimant was observed and videotaped displaying a full range of motion while working on vehicles, including a motorcycle, at his residence.
4. Combatting a common good day/bad defense often employed in these scenarios, surveillance continued and the claimant was observed not only working on and riding a motorcycle with a supposed low back injury, but proceeding to a private residence where he climbed a ladder and worked on a roofing project.
Bottom Line: Ethos Risk Services’ Data Support Services team uncovered an interest that would directly conflict with the claimant’s listed injury, and our field investigators finished the drill, obtaining over two hours of video of the claimant riding a motorcycle, performing vehicle maintenance, and working on a roof.
Positive Outcome: Ethos Risk Services employed both human intelligence and field-savvy investigators to obtain clear footage that directly contradicted the claimant’s injury. The third-party administrator subsequently presented this evidence and the claim was settled out of court, further saving the client time and money.
Case Exposure: $ 265,000 (Expect payout for claim)
Ethos case investigation resulted in: $195,400 Savings (case exposure – case investment = Savings)