Fraud Detection & Prevention Flashcards
7 cards from real CALA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Fraud Detection & Prevention flashcards as text
A claimant reports a slip-and-fall at a retail store but posts social media videos showing athletic activity on the same day. How should this evidence be treated?
Answer: It is a valid investigative lead and may be used as supporting evidence of fraud
Publicly available social media posts are generally admissible as investigative evidence and can directly contradict a claimant's stated physical limitations.
Which of the following best describes 'medical provider fraud' in the workers' compensation context?
Answer: A provider billing for services not rendered or upcoding procedures
Medical provider fraud includes billing for services not rendered, upcoding, unbundling, and other schemes that inflate the cost of treatment.
An insured presents a claim for a fire loss and investigators find the fire was set intentionally by the insured to collect proceeds. Which legal doctrine typically governs the insurer's right to deny this claim?
Answer: Public policy against benefiting from one's own wrongdoing
Public policy bars an insured from profiting from their own intentional wrongdoing, forming the legal basis for denial of arson-for-profit claims.
Which database does the NICB maintain to help insurers identify vehicles reported stolen multiple times across different policies?
Answer: ISO ClaimSearch
ISO ClaimSearch is the industry's largest claim history database, used to detect duplicate claims, prior losses, and patterns of fraud across insurers.
A claimant files a liability claim alleging injuries from a product defect but was previously convicted of filing fraudulent claims. How should an adjuster use this information?
Answer: It should be factored in as part of a heightened fraud review, along with current evidence
Prior fraud convictions are a significant red flag that justifies heightened scrutiny, but the current claim must still be evaluated on its own evidence.
Which of the following is an example of 'application fraud' that could affect an auto insurance policy?
Answer: Listing a lower-risk garaging address to obtain a reduced premium
Application fraud occurs when material misrepresentations are made at policy inception, such as falsifying the primary garaging location to lower premiums.
Under most state immunity statutes, an insurer that reports suspected fraud to a state fraud bureau in good faith is:
Answer: Protected from civil liability for making the report
Most states provide civil immunity to insurers and their employees who report suspected insurance fraud in good faith to authorized authorities.