Investigation Case Study Gary Sommerford, MInstLM, GCGI, ACFS counter fraud, risk, investigations & cost containment solutions

Scenario Subject had accident in Mykonos Severe abdominal injuries resulting in emergency evacuation to Athens Initially admitted to public hospital Transferred to Private Hospital €600, Bill

Timeline 05/07/2012 – Agent advises that subject was involved in RTC on 20/06/2012 Agent requested LoG for €100, for Private Hospital 17/07/2014 – Insurer unable to contact family Insurer requested medical reports, police report, itemised costs & estimate of further costs 01/08/2012 – Med Report and expenses now €250, /09/2012 Subjects wife contacts insurer advising that husband had been involved in RTC and was in Private Hospital ICU – Payment of bills requested Constant pressure from Private Hospital for insurer to provide LoG

Timeline 16/10/2012 Subjects wife contacts insurer advising that husband had not been involved in RTC and had in fact fallen on a construction site 07/11/2012 – New Medical Report provided by Private Hospital 12/12/2012 – Subjects lawyer contacts insurer requesting payment Insurer agent meets with subjects wife – During this meeting agent was notified of potential significant reduction in bill by Private Hospital Potential witness identified – Constructor (Uninsured as not required in Greece) Confirms injuries sustained as a result of fall on construction site

Concerns Circumstances Conflicting Accounts Differing medial opinion on potential cause of injuries Lack of information Transfer to Private Hospital & Unmanaged Costs Memory Loss of subject Coverage? Subrogation? Fraud?

Scope and Objectives Establish the circumstances of the accident Establish actions of all concerned Establish comprehensive timeline Interview witnesses Recover medical records and other documentation/reports Establish evidence of fraud Establish potential for subrogation Consider reasonable and customary costs

Conduct of Investigation Desktop enquiries & fieldwork Local agents Interpreter Translator Witnesses Police Public medical providers Private medical providers

Conduct of Investigation National Centre of Direct Help (EKAB) Hire Companies Greek Insurance Association Local independent medical professional Scene Photographs Video

Result of Investigation 20/06/2012 – Subjects wife advised of road accident by constructor and that subject was to be transferred to Athens 20/06/2012 – Agent received a phone call from subject requesting help as he was ‘dying’. Agent subsequently spoke with constructor who advised that assistance was needed transferring subject to Athens – Emergency Assistance number provided Agent also called number but it was not working!

Result of Investigation Mykonos Subject went to public clinic and discharged with minor injuries Subject then went to private clinic where he was diagnosed with serious chest and abdominal injuries requiring evacuation to Athens Unable to arrange private transfer either through insurance or personal finances EKAB – Via public clinic who were advised evacuation only

Result of Investigation Mykonos Enquiries with the police established that there had been no reported traffic accidents on or around the day in question and no reports bearing the name of the subject Enquiries with hire car companies established that there were no reported traffic accidents on or around the day in question and that the subject had not hired a vehicle Visit to the scene

Result of Investigation Mykonos Local enquiries established knowledge of an accident at the scene where the subject had ‘fallen down some stairs’ Attempts to liaise with the only witness (Contractor) proved negative. His daughter advised that he had travelled to his native Albania Contractor was seen on by site witnesses whilst he investigator was in Mykonos - Family advised of a dispute with the contractor over money

Result of Investigation Greece Documentation recovered from public hospital – Established subject spent 24 hours in hospital before being operated on - Following surgery, there were no beds available in ICU Subject transferred to private hospital ICU Meeting at private hospital – Recovered documentation and established that legal proceedings had been commenced Surgeon advised that report had been amended after being advised that initial report was incorrect

Result of Investigation Greece EKAB – National Centre of Direct Help In circumstances where no public ICU available EKAB must be contacted in order to allocate an alternative in another public hospital. Only if this option is unavailable will a patient be moved to private hospital. EKAB confirmed that they had been contacted and that there were no ICU beds available in any other public hospital

Result of Investigation Greece GIA – Greek Insurance Association No obligation to have and private insurance for third party liability Owner is to have insurance in place for any civil engineer and construction staff Civil engineer must be insured Subject was both owner and civil engineer – Uninsured!

Result of Investigation Reasonable and Customary Costs Independent medical auditors evaluated invoices from private hospital Doctors fees approx. 5% higher than customary All other costs in-line with similar hospitals in Athens No evidence of overtreatment or unnecessary tests

Result of Investigation Legal proceedings by private hospital against subject Legal proceedings by subject against public hospital for misdiagnosis and delaying treatment Insurer savings as a result of investigation approximately €500,000

DYSTICHIMA / ATICHIMA ΔYΣTYXHMA / ATYXHMA

Investigation A searching enquiry for ascertaining facts Detailed or careful examination Minute and thorough attempt to learn the facts

FOS – Financial Ombudsman Service Dim view of insurers who, through restrictive use of policy exclusions, implied that people were expected to refrain from drinking on holiday if they wish to remain insured Increase in complaints about claims being declined In many cases insurers assumed alcohol had been a factor Evidence

Why Appoint an Investigator Fieldwork is vital Remote communication would not have provided the same detailed information to enable confident informed decisions to be made Independent Open Minded Qualified and experienced Evidential Standards

BS – Code of Practice for the Provision of Investigative Services

licensing of Investigators Private Security Industry Act 2001

investigator compliance competence investigative service

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