Catching Fraud: Pot Hole Rugby

  • It is becoming increasingly clear that insurance fraudsters will go to extreme lengths to make fraudulent claims to insurers
  • Scott Clayton, Claims, Fraud & Investigation Manger at Zurich, has been featured on the BBC insurance fraud series ‘Claimed and Shamed’, in which he recalls the stories of a number of fraudulent claims
  • Following on from the previous episode, this claim centred on a man who had tripped in a pothole in the road, sustaining a serious knee injury.

It is becoming increasingly clear that insurance fraudsters will go to extreme lengths to make fraudulent claims to insurers. According to the ABI, the average insurance fraud is now worth £12,000, and the number of claims exposed as fraudulent has reached 1,300 per day.

Scott Clayton, Claims, Fraud & Investigation Manger at Zurich, has been featured on the BBC insurance fraud series ‘Claimed and Shamed’, in which he recalls the stories of a number of fraudulent claims.

Following on from the previous episode, this claim centred on a man who had tripped in a pothole in the road, sustaining a serious knee injury.

The incident

The claim, against a local authority, stated that the claimant stepped in a pothole in the road and sustained a knee injury as a result. “On the face of it, the claim seemed genuine because there was a defect in the road – if a person had actually tripped and sustained an injury then, on paper, it was possibly a claim to pay” explains Clayton. Due to the nature of the claim, and the injury sustained, Zurich estimated the claim to be worth £9,000 and began necessary checks before any cash was to be issued.

“As with any claim where there’s personal injury we needed sight of the medical records just to validate exactly what’s been claimed is accurate. So, in this particular case, the medical records came through and it did say there was a knee injury”, Clayton continues. With things stacking up, including evidence of a knee injury, it was looking like the incident had happened just as the claimant said. “We validate every claim, and that includes looking at the injury and whether it was consistent with what was being alleged.

Digging deeper into records

Whilst going through the medical records, Clayton determined that the injury was more consistent with one suffered playing sport, “the knee injury in this case, actually, the suggestions were that it was more likely to have been caused playing sport”. It was at this point, Clayton explains, that Zurich became suspicious of the claim, and what had actually caused the injury to his knee.

“Investigations looked into the background of this claimant, and we found out he was a rugby player, and quite an active one, so that was something we wanted to explore further”. However, the simple fact that the claimant played rugby didn’t mean he hadn’t suffered the injury from tripping in the pothole. “We carried out those inquiries so that we could get an idea of who we were dealing with”, continues Clayton. It was at this point that, Clayton explains, that the case took a sharp turn. “We found out that the claimant was actually playing rugby the day after he said he’d fallen in the street.” The inquiries into the claimant’s activities also showed that, whilst he had been playing rugby the day after he claimed he sustained the injury, he was substituted during that game as a result of an injury. That, according to Clayton, led Zurich to conclude the injury has actually been caused whilst he was playing rugby.

“Whilst the inquiries led us to conclude the claimant had suffered the injury playing rugby, we were also able to prove that he was playing rugby subsequently to his injury, meaning he had recovered and was back on the playing field”.

Referred to the police

After coming to the conclusion that this was a fraudulent claim, and because it was a claim made against a local authority, Zurich referred the matter to the police.

“They (the police) invited the claimant to come in for an interview, at which point he admitted that he had made an entirely fictitious claim”. Whilst admitting the claim was fictitious, however, the claimant also explained that he had been encouraged by his friends to make the claim against the council.

After admitting his guilt the claimant received a police caution which, as Clayton explains, will remain on his record. “The caution will remain on his record and potentially affect any future employment or references that people may seek against him, so it’s a hard lesson that he learned”.

To learn more about the topics discussed in this article, please speak to your local Zurich contact.

BBC’s Claimed and Shamed is a documentary series that highlights the ever-growing problem of insurance fraud, and follows the stories of claimants who were caught out. To watch this episode, or to watch past episodes, please click here.