Special Investigations Unit

The primary function of the SIU is to deter, detect, investigate, report and ultimately reduce insurance fraud. We believe fast, fair and efficient claims handling is the key to client satisfaction.

Insurance fraud occurs when people deceive an insurance company or agent in order to collect money to which they are not otherwise entitled. Conversely, it can also occur when insurers and/or agents conspire to deny a consumer a benefit that they may legitimately be entitled to receive. A key question to answer when faced with the possibility of fraud is whether the situation is truly fraud or just an exaggerated or inflated loss.

The most common types of insurance fraud include claim fraud, premium fraud and vendor (or provider) fraud. Incomplete or inaccurate information on a claim form or application does not necessarily represent insurance fraud. For it to pass the test, four key elements need to be present:

Intent: The person(s) must intentionally and deliberately deceive the insurer(s).

Knowledge: The person(s) must have knowledge that what they are doing is wrong, or is a false statement of fact.

Misrepresentation: The person(s) creates or assists in making a false impression that leads the insurer to pay a claim.

Reliance: The insurer would not have paid the claim but for the misrepresentation.

To summarize, in order to meet the definition of fraud, it requires an intentional, material misrepresentation in order to obtain a benefit.

JT Investigations believes that every case must be investigated on its individual merits. Our objective is to establish the veracity of the information presented and report on any potentially fraudulent or non-meritorious claims in an objective and professional manner.