Malingering? Investigation of Fraudulent Claims and Receipt of Insurance Benefits in Japan

In recent years, the issue of fraudulent insurance claims has become a social problem highlighted in the public eye. Among these, fraudulent claims due to malingering bring significant losses to insurance companies and lead to unjustified increases in premiums.

“Something seems off…”
“This person has made multiple claims in a short period…”
“We need to look into this further.”

This article explains the signs that may trigger suspicions of malingering, the process of investigative actions by detectives for fact-checking, and introduces actual case resolutions.

Introduction

The issue of fraudulent insurance claims has become a notable social concern recently. Particularly, claims made under false pretenses of illness, or ‘malingering’, cause significant financial losses to insurance companies and lead to the unjust rise in insurance premiums. This article discusses the triggers of suspicion for malingering and details the investigative process carried out by detectives to verify the facts, along with real-life
resolution examples.

Triggers of Suspicion for Malingering

The initial suspicion of malingering usually arises from signs such as:

• Past claim history: Multiple insurance claims made by the same individual.
• Doctor’s medical certificates: Ambiguous diagnosis or certificates issued only by specific doctors.
• Lifestyle patterns: Inconsistencies between social and professional activities.
• Witness information: Reports of unusual activities by neighbors or colleagues.

These signs can trigger suspicion of malingering within insurance companies.

The Process of Investigative Actions

When suspicion of malingering arises, insurance companies typically hire specialized detectives or investigation firms to conduct a behavioral investigation. The investigation process is carried out as follows:

• Preliminary investigation: Gathering information on the subject’s lifestyle, social relations, and past insurance claim history.
• On-site investigation: Observing the subject’s daily activities, range of activities, and social interactions, documenting with photos and videos.
• Evidence collection: Gathering relevant evidence such as medical visit records, prescription records from pharmacies.
• Analysis and reporting: Analyzing collected information and evidence to determine the existence of malingering and reporting to the insurance company.

About Fraudulent Claims and Benefit Investigations


Fraudulent claims pose a disadvantage to insurance companies. Our office conducts fact-checking through behavioral investigations based on preliminary information about the subject, then submits a report. Based on the investigation results, insurance companies can accurately understand the factual circumstances regarding suspicions of malingering.

Surveillance includes:

• Monitoring entries and exits of the subject’s home.
• Watching the subject’s visits to hospitals or clinics.
• Monitoring the subject’s usual behavior.
• Inquiries around the subject’s environment.
• Checking the subject’s social media (SNS).
• Collecting evidence and creating investigative reports.

In past cases, there have been instances such as “the subject did not appear at the clinic at the time of the appointment,” or “a specific doctor at the clinic was cooperating with fraudulent claims.”

Resolution Examples


As an example, there was a case where a man in his forties claimed long-term disability benefits citing an injury. However, the insurance company became suspicious due to his social media activities and information from neighbors. Detailed investigative actions by detectives revealed that the subject regularly visited a gym and engaged in heavy weight training. Furthermore, photos of him participating in a local sports event were posted on social media. Based on these pieces of evidence, the insurance company stopped the payment of the disability benefits to the man, who then admitted to the fraudulent claims and returned the received benefits. In this case, detective-led investigative actions played a crucial role in proving malingering.

Conclusion

As outlined in this article, detective-led behavioral investigations serve as an effective means to unravel suspicions of malingering and prevent fraudulent insurance claims. Insurance companies should act swiftly and cautiously when they suspect fraudulent claims, establishing measures to prevent misconduct preemptively. Simultaneously, strengthening collaboration with detectives and investigation firms is essential in conducting trustworthy insurance operations. We also accept requests from abroad. With corporate-specialized investigation staff on board, please feel free to consult with us.