Insurance Fraud Investigation: Method, Evidence, and Interviews
Investigation is a disciplined search for facts
An investigation turns a referral into an evidence-based account. Start with a plan: scope, hypotheses, evidence needed, legal and privacy constraints, and decision points. Identify the claim theory and the alternative explanations you must test. Evidence may be documentary, physical, testimonial, digital, or observational. Preserve it: chain of custody, metadata, original recordings, and contemporaneous notes. Interviews should move from open-ended to specific, avoid leading questions, and never promise leniency or pretend to have evidence you lack. Recorded statements and examinations under oath have formal rules; know who authorized them and what the policy requires.
Common traps: treating an interview as a confession hunt; ignoring exculpatory evidence; letting confirmation bias drive the file; mixing fact with opinion in reports. Surveillance and social-media review must be lawful, relevant, and proportionate. Coordinate with counsel when litigation is reasonably anticipated, and document why each step was taken.
Worked example: an allegedly disabling injury. The plan should test the injury claim, the accident mechanism, and the treatment pattern. Obtain authorized records, compare them with the claimant's activities, and interview witnesses before confronting the claimant. The report should separate verified facts, unresolved questions, and conclusions. Rule of thumb: if a finding cannot be explained to a skeptical reviewer from the file alone, the investigation is not finished.