Auto Insurance Claims/Accused of Fraud

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Question
QUESTION: Hi, my boyfriend has been accused of putting in a fraudulent claim on his car insurance for hail damage because the adjustor at the dealership included other damage on the vehicle not related to hail. Ironically this was his first claim with the company and has been covered through them for 10+years. He told the adjustor to just estimate the hail damage and the estimate came in it was not clear to us what the line items related to as this is not our field of expertise so we sent it to USAA. They sent someone out and estimated 1K damage so we asked why the large difference. They explained the original estimate included mechanical damange (we still have no idea what that is). They also are accusing him of damaging his own car, yet even their appraiser saw hail damange. Now they are investigating him. His is currently in the National Guard, a former Marine, works full time and we have a family. This threat is stressing our family out and not sure what to do exactly. Do we let it ride out and see what happens or get an attorney that we can't afford?

ANSWER: They will probably ask him to sit for an examination under oath, which is similar to a deposition.  They will also probably ask for documents related to finances and/or other issues.  If you wish to pursue the claim and payment, you will need to cooperate with these requests.  If you refuse, they can deny the claim for non-cooperation.  Make sure you are completely honest about every detail because any type of misrepresentation would also be grounds for denial.

If they determine they have sufficient evidence to prove fraud, they can deny the claim and refer their file to law enforcement.  However, there are two legal standards here:  civil fraud would be grounds for denial of the claim, and for that they only need to show it is more likely than not that fraud occurred.  To prove criminal fraud, law enforcement would need to prove fraud beyond a reasonable doubt.  It is far more difficult to prove criminal fraud than it is to prove civil fraud.  So criminal charges would be unlikely.

This is a judgment call, so I can't tell you what to do, but I can try to explain the things to consider.  It is your choice in the end.  If you drop the claim, it will probably end there, but you won't get paid.  If you pursue the claim, you might get paid, but you risk the possibility of law enforcement involvement.  An attorney can give you good advice, but will be costly, and would likely cost more than the value of the claim.


---------- FOLLOW-UP ----------

QUESTION: Thank you, but we offered to drop the claim but was told we couldn't since it's being investigated because for a$1k claim after deductible would be half. Really not worth this hassle. Why would they not let us close the case? No $ has exchanged hands yet?

Answer
You can withdraw your claim at any time.  They cannot make you pursue a claim.  You have no obligation to cooperate or even speak to them if you choose to drop the claim.  If I were you, I would tell them to stop bothering me,  or I'd sue them for harassment if they won't leave me alone.

If law enforcement becomes involved, that would be different, and you would need a lawyer at that time.  Good luck.

Auto Insurance Claims

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Claims Guy

Expertise

I am currently an Auto Claims Manager for a large insurance company. I have 20 years experience in the industry, having worked as a Claims Adjuster, Injury Settlement Negotiator, Claims Manager, SIU/Fraud Investigator, and Compliance Officer......I can answer questions related to any aspect of Automobile insurance claims and coverages. I can provide an inside look at how insurers operate. I always treat my customers fairly and want to help make sure you are treated fairly. However, please keep in mind that being treated fairly according to the law does not guarantee that you will get what you want. I can also answer some questions regarding Homeowner's and other types of insurance claims. I have handled all types of auto insurance claims and coverages. I am NOT an automotive repair expert but can give advice re how insurers handle complex repair issues. Please keep in mind that every state has its own set of laws pertaining to rules of the road, liability, and insurance. No one is an expert on every state. I am most familiar with laws in Maryland, DC, West Virginia, and Virginia, but will attempt to answer questions for other states. I am not an attorney an cannot provide legal advice. My advice will be my opinion based on my experience.

Experience

I am currently an Auto Claims Manager for a large insurance company. I have 20 years experience in the industry, having worked as a Claims Adjuster, Injury Settlement Negotiator, Claims Manager, SIU/Fraud Investigator, and Compliance Officer. I am not an attorney an cannot provide legal advice. My advice will be my opinion based on my experience.

Organizations
CPCU Society. Adjusters license in multiple states. International Association of Specal Investigators

Education/Credentials
I have a B.S. in Finance and have completed the AIC and CPCU designations.

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