"We had a claim in Los Angeles where the video showed an alleged Permanent Total moving a 300lb refrigerator. He was actually carrying it for about 20 feet on his back. The DA refused to pursue him because the video wasn't "clear" with respect to his face. The man was 290 lbs, had a fu manchu mustache, hair down to his belt line and he was driving the same exact truck owned by the claimant. Forgot to mention his arm had the same tattoo."
As an investigative firm it is our goal to "catch the bad guys" and get the claims professionals the information necessary to reduce your exposure. Your goal as a claim professional is to save your companies money by putting your company in the best position to mitigate a lower overall settlement or to disprove the severity of the injury to the claimant. All this while ensuring you have followed the claims process to the letter and making sure the people that truly need workers comp. assistance gets it.
In this particular case we have to remember that the percent of insurance fraud cases that actually go to full litigation in the criminal courts are in the single digits. In criminal cases you need to prove beyond a reasonable doubt that your claimant is doing wrong. But in civil cases, which most claim cases fall into, you just have to prove the preponderance of the evidence favors your side. 51% probability of being right is all you need.
A claims adjuster must understand the correct course of action is to pursue the matter through the civil route. For this case study the reputation of the investigative firm and their ability to provide video evidence as well as eye witness testimony is key to verifying the identity of the claimant. Expert testimony can help verify that the person on the video was the claimant by offering clear points that A + B must equal C. Using the testimony of an investigator who witnessed the claimant close up, and witnessed the claimant repeatedly exiting the home which is owned by the claimant, and fits the overall description of the claimant, and is getting in the vehicle registered solely to the claimant, we can logically conclude that it is the claimant.
In civil cases it's all about being 51% right.