In the 1970's, I was injured on the job and again, in a subsequent automobile accident. Together, both caused enough physical damage to make carpentry a thing of the past for me.

From the beginning, it was delay, denial, and accusation. They could not refute the broken bones and tissue damage, but beyond treatment for the physical injuries, there was no help and always a delay in benefits.

It was explained to me that all the fraudulent claims submitted by other individuals had caused the trouble in my claim. Although an unpleasant experience, I accepted the explanation, believing there were unscrupulous people in the world that would try to steal from an insurance company. I was mad at "those" people; however, I was younger then.

As a part of my recovery and rehabilitation, I enrolled in a small college and began computer-programming classes (real big in the late 70's), but I hated it. I had always worked outside and "built things"; a real man's job, you know "Macho". Now, I was sitting in a classroom with no view, no noises, and I couldn't even smoke a cigarette. It was just a boring classroom filled with technical books and blank chalkboards.

I had attended classes for about a month when my brother called to tell me he knew a private investigator that needed a van for the weekend. My brother was working on the PI's vehicle and had mentioned to him that I owned a van. Well, I called the PI and we worked it out; I would tag along as an observer/driver for the weekend. He was going to pay $50.00 per day for the van, feed me, and let me watch how to investigate "insurance fraud". On the following Monday, I was hired as an investigator, given a notebook and a wind-up camera, and never returned to computer classes.

For close to three decades, I have been an insurance fraud investigator, providing insurance companies across the United States with "That One Shot" they needed to reduce and or eliminate exposure, deny claims, and used to prosecute "Insurance Fraud". It's called "Claims Management" and should never be confused with compassionate care for an injured person.

People ask why "Insurance Companies" are so ruthless; why the Government does nothing, and how can "They" do this to "Us". All the wrong questions, it is not them against us, entities cannot create or change the system; it's the people; character, ethics, morals, and individual motivations guide all people, in all walks of life.

Insurance is a business, which by definition means "profit-based", and are not health management, patient care, or compassionate care providers. Claims adjusters, examiners, or whatever you call them, are not trained to provide care, income replacement, and/or positive support, unless they absolutely must. However, they are trained to examine, explore, manipulate, and resolve (close) claims. This is true for all types of insurance, e.g. Workers' Compensation, auto, home, disability, life, etc. They are all "for-profit" entities that take risks based on projected returns.

The business of insurance is not to blame, it is the people who make the rules and those who break them, or, at the very least, bend them just to the breaking point. As a "Big Player" in the lobbying of governmental bodies, Insurance Companies are like any other special interest group and know you get what and whom you pay.

With the discretionary powers assigned to those people in charge of benefits, you inject the "human" factor directly into the claims process. Decisions are made, actions are taken, and attorneys evaluate risks everyday regarding every level of the business. Remember, the biggest liability to an insurance company is open and active claims and the best way to improve profit is to eliminate liability, or debt, in the most cost effective way available.

The concern should be focused more on the individual behavior of the claim handlers, from the examiner to the supervisor of an entire unit. By following the rules, legitimate claims would be handled more efficiently and fraud could still be investigated, detected, and resolved.

However, as people go, there will always be those who believe they can cut corners and make and/or save more money by stepping outside the law; Claimants, Examiners, Adjusters, Private Investigators, Doctors, Attorneys, and Judges as well.

Never forget that attorneys, at the direction of company CEO's, CFO's, COO's, and Boards of Directors, write the directives that create this quandary.

With that said, Claimants are considered a negative to the company's business plan and claims staff are trained that they represent the largest cut in company profits; usually a continuing debt by virtue of what is called "Reserve Accounts". Reserve Accounts represent cash that is set aside to pay for claims and reduces a company's bottom line.

Claims Management is only a term; it's meaning is scarier than its use. The meaning of Claims Management, in simplest terms, is to manage (reduce) the amount of money it takes to resolve (close) a claim. Those with a business background and educated in the "legal" ways to reduce exposures are hired and trained to exploit the claims process in the name of profit.

In all my years in the business, I can count on one hand the number of Claim Adjusters and/or Examiners who provided assistance and/or real advice to an injured person; an exception to the rule. Most I've worked and/or have interacted with believe all claimants represent some type of exaggerated or fraudulent claim.

In the beginning, I too believed fraud was exclusive to claimants; they were the only ones with a motive, because it meant "free money" to them. Insurance companies and their defense teams claim that all injury claims are questionable and each should to be closely scrutinized for fraud, or at the very least apportionment.

Claimants are, for the most part, ignorant of the legalities and terminology used in the claim process. They are usually confused and focused more on their injuries, pain, depression, and are usually trying to figure out where rent and food money will come from, let alone how to pay their everyday bills.

On the other hand, claims adjusters/examiners are just doing their job. They are trained, educated, and experienced in the process. However, adjusters/examiners do not have the same looming issues to worry about and know a claimant is vulnerable, easily manipulated, and an easy target from the onset of the claim.

Over the past few decades I have watched the defense of insurance fraud become a practice of the past, replaced by the defense of claims instead, to defend all claims, not just the questionable ones. This is what has led us to where we are today; insurance company directives have changed in such a way to facilitate quicker, more efficient claim resolutions, even the expense of closing legitimate claims through questionable means will increase profits overall.

Along with everything else is the "human" factor, which may be the most abhorrent element of the claim process. Today, we are faced with more fraud from within the industry then ever before, but claim handlers are protected by the "system".

Workers Compensation, with its "exclusive remedy" and Employer Provided Benefits, governed by the Federal Law, "ERISA" (Employee Retirement Income Security Act of 1974) and its "Preemption" clause afford no incentive for insurance companies to abide by the rules. In fact, the protections offered the insurance industry have the opposite effect and provide an easy way to abuse the system and violate current state laws without fear of retribution.

The most serious defect of both systems is that no real audit, enforcement, or statutory penalties are in place to act as a deterrent. Therefore, by doing the math one can better understand the mindset of those in charge. In systematically eliminating claims, legitimate or not, the only real exposure at risk would be the original benefit and maybe some attorney's fees. This alone creates a hostile environment and allows the abuses to continue at an acceptable level of expense when compared to the increase in profit.

The goal of the industry has nothing to do with the cost of an individual claim. A single claim is nothing more than a small part of the total "statistical" outcome the insurance companies monitor. Moreover, there is no consideration to the medical aspect of a claim, it is only how to best maintain the level of exposure (amount of money) it will take to resolve the claim.

For example, 100 claims filed and denied will result in only a small number (less than 10 percent) of Claimants who fight back. Most just accept the denial as a painful reality and succumb to the abuses of the system. Of the few that do file a grievance or an appeal, only a small number of those will result in benefits being awarded and most will be denied due to the discretionary clauses designed by, and exclusively for, the insurance industry. Remember, insurance is a business and a claim is a debt that has to be resolved.

Unfortunately, the more one demonstrates an ability to resolve claims, by whatever means, the more claims and/or claim handlers they will be responsible for, which will save the company even more money. Eventually, greed becomes the motivation; the greed of the industry's desire to make a profit, coupled with the individual greed of an adjuster or examiner to be paid more for their work; morals, ethics, and adhering to the law become secondary considerations.

There is a psychology used in the claim process that makes this all easier to live with, except for the injured person. You will note that there are no personal references; almost always terms like the injured worker, Claimant, Patient, and/or Applicant are used in place of more human terms, this step alone removes the need or desire to be compassionate or caring when evaluating a claim. If you are nothing more that a statistic, you will never be respected as an individual or even seen as an injured person.

Always remember, much like an "underworld enforcer" would say, "nothing personal it's just business".

Private investigators have always suffered a "bad rap" from their work within the insurance industry. Both the injured person and claims reps see us as an evil tool; Claimants fear us and adjusters think we charge too much for our services. To some respect, both are right to feel this way. Private Investigators are people too and have the same "human" factors to deal with.

Choosing the arena of insurance defense, for an investigator, means you will be judged by your ability to assist in reducing liabilities. We are trained and educated to provide a service and to remember that we are only as good as our last report.

Should your work fail to provide "positive results" on a consistent basis, you will be replaced by someone who will. The term, "positive results", means the documentation required to reduce or eliminate claims and nothing else.

Private investigators are routinely asked to violate the rules, ethics, and guidelines. In fact, private investigators are often requested to skirt the laws and violate rules of evidence to defend a claim.

The most common request is for "selective" evidence gathering. By selectively choosing the evidence obtained (videotape) we often fail to represent the true picture regarding an individual's physical abilities and ultimately this leads to a decision based on what "we" think is important. In my work, we should videotape everything and let those who are trained to evaluate what they see to decide what is important. Another way to abuse a discretionary clause is by allowing a claims administrator or defense attorney to omit material, factual information from a claim file.

Private investigators are supposed to be unbiased fact gatherers and are not to ignore any evidence discovered. We should only be concerned with the information needed to evaluate the true abilities of an individual and not try to present such a one-sided view of the person we are investigating.

On occasion, private investigators are requested to mislead a Judge or Jury during their testimony. Something you have to learn to do is not "lie" in court by learning how to legally frame your answers to fit the specifics of the questions asked. Other times, investigators are asked to just break the law and provide evidence, which has been altered, and to pass it off as "Original" evidence.

I know of a large private investigation firm who was accused of routinely abusing the rights of their employees, those of the injured person, of providing fraudulent surveillance reports, claiming activity that did not occur, and for billing the insurance companies for work that was not done. It turns out there was a pattern to this abuse of the system that included the cooperation of some of the insurance companies reps and the management staff of the investigative firm.

There are defense attorneys who make unethical and illegal requests; asking private investigators to assist in "tipping" the scales to their benefit, as well as, claims reps who think nothing of violating privacy laws to obtain any information that might assist in the resolution (closure) of a claim.

My knowledge is not just from the stories of others, although I have heard numerous, it is from my personal experiences over the many years I have been a fraud investigator.

When I started, we could "Rope" a Claimant, using various tactics to entice a Claimant to perform activities he/she claimed they couldn't do. I personally have carried an ice pick, loose coins, an oilcan, water balloons, a bicycle, skateboard, tools, and even age appropriate toys; matched to a specific claimant, their family and their combined lifestyle.

The use of "Roping" techniques was banned years ago and is considered a criminal offense under the term, "Entrapment".

Items such as those listed above can almost always create a set of circumstances that leave a claimant vulnerable when interpreting the videotaped activity. Imagine the following:

Waking up in the morning to a plate glass window (living room) that has been smeared with oil or Crisco grease; or

Opening your front door and finding a walkway and/or front yard littered with coins; or

Walking to your vehicle and finding you have a flat tire (usually rear passenger side) while away from home: or

Having a full water balloon land and splatter a few feet behind you as you walk through a parking lot, etc.

These are only a few, of many, times when a Claimant's physical activity would unfairly influenced, but will usually provide a "positive result" for the investigator to videotape.

Even a sudden blast from a load horn, radio, or of someone screaming your name can result in a "positive result", captured as "that one shot".

Remember, it is not just the activity we can create, it is also knowing that a claimant is not educated in the claims process and usually has no understanding of the legal terminology used to define the claimant's own words. Claimants generally use words like Can't, Don't, and/or Won't, when describing their abilities, limitations and/or restrictions. They will use terms like, can't bend over, use my hand, climb stairs, run, and statements like, don't walk without a cane, climb stairs, drive, do housework and/or lawn work, and won't be able to do that again. More often then not, a claimant can do those activities to some degree or another, even if for only a brief moment in time.

We refer to those as "four-letter-words" and see them as immediate indicators (red flags) of fraud, or at the very least, a legal way to use the claimant's words and a short videotape to reduce benefits or eliminate the claim entirely.

The trick is the wording and how it is defined in a legal setting; can't, don't, and won't are specific terms. However, just because someone can bend over to pick up money from the ground on one day, does not mean it did not hurt or cause problems, subsequent to the event. The videotape will only show the "positive result" needed to discredit the claimant's statements. The examples are endless, but it always comes down to what is seen on the videotape or read in the reports.

Another, widely used, investigative technique is called Pretext Investigation. This is when an investigator, claiming to be someone else and, with a made up reason, is now talking to you, your friends, and/or your family. A good technician (investigator) will almost always give their name, where they are calling from, and finish with what it is they think will capture someone's attention; every bit is a lie and is designed to keep you talking with, not questioning, the caller.

This method allows us to obtain information from an unsuspecting source, which we then exploit and try to use against the claimant. Pretext investigations are designed to elicit information not otherwise available or discoverable in litigation, and are almost always omitted from an investigation report.

In surveillance reports, we refer to this technique by using terms like, "a confidential source" or "a neighborhood source", "further investigation determined", "discrete inquiries", "neighborhood canvas", and even 'further information obtained". These are clear indicators that the information contained in the report came straight from the claimant. However, it could also be from a neighbor, a friend, and/or a family member. The practice not to identify the source is not only common, but also necessary when legal counsel represents the claimant.

A common direction from a claims adjuster, examiner, or defense counsel is to not videotape or document anything that would support the claim. They do not want to show a claimant in a wheelchair, using a cane, or with crutches. It is not helpful to the defense to have a videotape of a right-handed claimant forced to use the left hand due to their injury. And, noting children doing lawn work or someone else changing the oil should never be noted in a surveillance report, as it would support the injured person's claim that he/she cannot.

The exception to this type of request is when you actually have a fraudulent claim to investigate. Though few and far between, there are people who try to fraud the system, and some get away with it.

A good example would be an individual claiming a low back injury (soft tissue) and has stated they can't bend, lift, or climb stairs, and suffers all the time. All the while the claimant mows lawns, works on cars, and participates in family sporting events. When the individual shows up at a medical appointment, or even better, to a courtroom, unable to walk without assistive devices, confined to a wheelchair, or so medicated (to "control the pain") that they are barely coherent, you are watching insurance fraud occur.

Again, the above is a less common then thought; for the most part, the injured person is really injured and only has "good moments" that usually last for short periods of time throughout their daily lives. Some injuries are short lived and some are permanent in nature.

Of course statements from claimants are subjective, but so are the statements from medical and legal professionals, and all need to be addressed and assessed as such. Most claimants are honest, hardworking people that just got hurt, want to heal, and return to their work-a-day lives, which I would say is the norm; however, some also are prone to need more healing than others. And, there are those who will abuse the system to stretch their time off work and/or to increase the final benefit award.

How information is obtained and/or used needs to be understood. Written information can be from unidentified sources, such as a disgruntled ex-spouse, a busybody neighbor who really doesn't know, but needs the attention, and/or coworkers who just want to "help the boss". More often than not, the information is rarely verified or confirmed though an independent source, and is almost always damaging to the claimant's claim, even when incorrect. Although, just having this in the report will taint the claimant's version.

Videotape is thought to be the most objective information available when evaluating the true physical abilities of an individual claiming an injury. It is not objective if the investigator is selective.

Investigators often spend a number of days, over several months, and sometimes several years obtaining videotaped documentation of a claimant's daily life. These surveillances are sometimes conducted close to medical legal appointments, which usually include the day of the appointment, on weekends, and holidays too. A claimant's birthday is often a good time to watch them as well.

Unless the overall activity disproves the claimed restrictions and/or limitations, it is likely going to be copied, in a shorter version, and will only show the "best" activity. A lot of times hours of videotape are reduced mere minutes when shown to a doctor, who will then write a medical opinion regarding the injury and the level of disability it causes the individual.

To avoid editing, which is not allowed, and to consistently produce "positive results", the investigator must learn to be selective, based on the activity observed. To be selective in obtaining videotape, an investigator must learn to employ ways to justify gaps in time and why other activity could not be videotaped; not to lie, but to learn the ins & outs in order to avoid anything that would or could support the claim.

It is a vicious circle of corruption that needs to be exposed in order to be broken. This all revolves around money; from the corporate greed of the insurance industry, the cost containment practices of a third party administrator, the burned out and/or unethical, but almost always unqualified medical professional, unscrupulous defense attorneys, and unethical private investigators. This circle of people all feed from the same trough, the public. The high cost of premiums more accurately refers to the money it takes run a profitable business. This ensures the trough has a continuing supply for all to feed from, in an attempt to avoid paying claims, legitimate or not, as a form of job security.

The fraud we combat is much less than the fraud we commit in our effort to defend insurance claims. We have failed to maintain the integrity needed to support the system and most of us have surrendered our ethics to the almighty dollar; again, big business knows you get what and whom you pay for, and it seems just about everybody has a price.

From the initial filing of a "DWC-1", or "The Claim Form", every claim is immediately suspect, and the process begins. A claim process designed to "provide medical and/or financial benefits" is a deceptive use of words. The true nature of the claim process is to limit and deny benefits, and resolve claims as quickly possible.

To be fair, as fair as possible, it needs to be said that there is a certain level of fraud committed by individual Claimants, organized gangs, chiropractors, doctors, plaintiff attorneys, and other medical legal professionals. However, the level of fraud detected and prosecuted in the private sector is negligible and pales in comparison to the level of wrongful denials, delays, and the termination of benefits regarding the thousands of legitimate claims filed each year.

I am sick and tired; sick of what we (the defense) have become, today, and how what we do is justified by what we get paid and not by the ethical standards we once followed. And, I am tired pretending I am proud of my profession, as it is today, in the arena of insurance defense. Have we become an essential part of the system, used as a tool and designed to facilitate the fraud committed within the industry?

Over the past twenty years the scales have been tilted as a result of greed and the need for "status" among our peers. Company executives are paid million dollar salaries based on company profits, defense attorney's paid to defend their actions more than the decisions they make, doctors are more willing to prostitute their credentials in order to write "proper" medical reviews, and private investigators are willing to ignore, forget, and alter information to provide "positive results".

No less important, but certainly with more impact, lobbyists for the industry travel in an altogether different circle, a circle that is isolated from the rest of us, the congressional, legislative and judicial arenas. Here we have a group of individuals who operate behind the scenes and in ways we only talk about, but can do little to change. As I said, "you get what and whom you pay for", and the amount of money spent at this level is to influence, convince, or entice the actions and opinions of our leaders. These are the protectors of the very system we depend upon to protect us from the abuses we claim to suffer.

Look around and listen to others as they complain about the "system". You will hear people talking about entities in general, but rarely do you hear the complaints regarding an individual by name. The "system" is not to blame; all systems are flawed in one way or another; "rules are made to be broken", and lawyers are there to defend you when you break them.

The integrity of any "system" is only equal to the level of integrity of those who operate within it. If there is no personal integrity, there will be no integrity in the system itself.

In all things, it is the people and their collective "human" factors that form the foundations we build upon, both personally and professionally.