Cheating the Cheater
The Situation
A few weeks ago we were contacted by a local restaurant owner. He felt he was being duped by an injury con artist. He owns a local franchise sandwich shop and was able to keep on three of their eight employees. The shop had curbside delivery, but it also had carry-out service. One customer came in to pick-up their food, but slipped and fell on some water that no one had seen. The owner found it strange that the floors had been moped a few hours earlier and he had no idea where a puddle of standing water could have come from. I had my suspicions.
The Assessment
The owner of this franchise branch had sunk every dime into this place and he and his wife were working seven days a week to turn a profit and during Covid, that isn’t easy. I hate unethical people who try to rip off honest business owners. We took the case.
The doctor that she was going to was appointed by the insurance company. That doctor recommended not just x-rays, but also an MRI and physical therapy at least four days a week. Since most places are being Covid careful, the therapy was conducted in her home by a physical therapist licensed to operate in private residences.
We Went to Work
This was going to be an all shoe-leather team.
First, we placed a small camera to the mailbox post, just under the edge of the mailbox so that we could see the “patient” coming and going. We also attached another camera to the street-side edge of her fence, looking into the back yard.
We obtained copies of her medical records, x-rays and doctor reports. Since we were working for the client, the insurance company was happy to give us these. After all, we were trying to prove fraud and in the end, save them from having to pay out a huge sum of money.
The “patient” was hobbling around in a neck brace, a sling and using a cane for her ankle that was in a boot. The doctor stated that she had soft tissue damage in her neck, a possible broken coccyx (tailbone), ligament damage in her ankle and shoulder. All of these problems were going to take many months of therapy, possibly years. The attorneys were already salivating.
The cameras weren’t sending us any images that proved she was faking it. The shoe leather team wasn’t having any luck either. But, I have been doing this a long time and experience is always the best teacher.
I took all of the medical records, scans and x-rays to an independent orthopedist that I know very well. He studied the x-rays and shook his head, laughing. I wanted to know what was so funny. He said that every one of the pictures/films/scans showed exactly what the doctor said was injured as a product of the fall. What it didn’t show was a woman’s body. These films and records were of a male patient several years older than the middle aged woman who “fell”.
Cheaters NEVER Prosper
I knew there was something fishy. So, now, the cyber team was involved. I notified the insurance adjuster of the possibility of Insurance Fraud and probably not in just this case. Since their doctor was their “go-to” expert, they had no reason to doubt him.
The cyber team found that the traveling physical therapist company was partially owned by the “go-to” doctor. As was the MRI company. Talk about conflict of interest!
In the end, the shop owner didn’t pay out a dime to the “slip-and-fall patient”, the insurance company would have had to shell out tens of thousands of dollars if they had settled based on their “go-to” experts advice and the doctor and the “patient” are now doing jail time for fraud.
It is estimated that insurance fraud scams like this steal $80 billion a year across all lines of insurance. That ends up coming out of the consumers pocket. At Michael Guadagno & Associates, we have a team dedicated to serving business owners and insurance adjusters to ensure they are not getting cheated. We are always looking to partner with local businesses as their on-call Special Investigations Unit. Give us a call at (919) 363-6321 to set up an appointment. Let us handle the leg work while you continue running your business.