The 'W7 Standard' for Special Investigations

Of all paid out claims received by European insurers an estimate of 10% is expected to be fraudulent. The following list of reasons make prevention, detection and proving fraud challenging for insurance companies:

• Lack of internal structure in the process of special investigations.
• Limited legal options in case of fraud suspicion, or even when proven.
• Special Investigations departments stand alone; the overall organization is not as worried about fraud prevention.
• Outdated technology; which can go as far as depending on excel files and experience in the heads of individuals within the organization.
• Poor data quality; makes it virtually impossible to determine the cause of anomalies.
• Strict privacy laws; making it hard to investigate suspicious claims properly.
• Lack of (qualified) staff due to budget constraints.

In this white paper, we lay out the W7 Standard, derived from the '7 golden W questions' of forensic investigations. Organizations that follow this Standard can optimize their overall investigation outcomes. When this happens, more cases are successfully solved in less time, the evidence is more reliable, sanctions are easier to justify, and reclaiming the damage on the perpetrators becomes more fruitful. Another benefit of this process is that it makes it easier to exchange data between different parties in larger investigations. Cooperation becomes more effective, as cases are always complete, compatible, and easier to understand.

This white paper also explains how to substantially reduce workload by digitizing the first part of the process, using data and automated solutions. Answering the first four questions of the W7 Standard as part of your fraud monitoring routines results in signals with an accurate indicator of suspicious activity, therefore the system generates less false positive alerts. Leaving more time for claim agents to properly handle and assess the generated true positive alerts, resulting in only relevant cases being sent to the special investigations unit.

An added benefit of the W7 Standard is that it makes organizations more compliant with privacy regulations as it is easier to shield personal data and to allocate authorizations.

Applying the W7 Standard to the audit trail as well as to the ‘standard’ investigation process improves overall accountability of the results, relevant under the GDPR regulations. Accountable results are vital to justify proportionality for proposed sanctioning measures and to ensure that cases are eligible for lawsuits when and if necessary.