Episode 5 Claimed and Shamed


Episode 5

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Transcript


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Insurance fraud has reached epidemic levels in the UK.

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It's costing us more than £1.3 billion every year.

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That's almost 3.6 million every day.

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Deliberate crashes, bogus personal injuries, even phantom pets.

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The fraudsters are risking more and more to make a quick killing

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and, every year, it is adding around £50 to your insurance bill.

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But insurers are fighting back,

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exposing just under 15 fake claims every hour.

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Armed with covert surveillance systems...

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Subject out of the vehicle.

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..sophisticated data analysis techniques...

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..and a number of highly-skilled police units...

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Stay where you are!

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..they're catching the criminals red-handed.

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Just don't lie to us.

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All those conmen, scammers and cheats on the fiddle

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are now caught in the act and claimed and shamed.

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A flashy fraudster shows off his ill-gotten gains...

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Exotic foreign holidays, exotic cars,

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we've identified £80,000 plus that couldn't be accounted for.

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It's a family affair, as one scammer steals from her own grandmother.

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This was so premeditated.

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I should imagine she's extremely unpopular in her family.

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And one claimant develops a very convenient case of amnesia.

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If you're a 17-year-old trying to get insurance on your first car,

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the premiums can be eye-wateringly expensive -

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well over £2,000 a year.

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And it goes up from there if you happen to be male,

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so if a broker offered you a much lower price,

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you can see why the temptation would be there to go for it,

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even if you thought it all sounded a bit too good to be true.

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It's these sorts of high-risk individuals that so-called

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ghost brokers target, as Clare Lunn

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from insurance providers LV explains.

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A ghost broker is an individual or group of individuals who set up

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policies for the general public,

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deliberately misrepresenting the risk to obtain cheaper premiums.

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So, a ghost broker might sell a policy to a 17-year-old,

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but get a cheap price, by telling the insurer

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it's for an older, lower-risk driver.

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The ghost broker then pockets the difference between what the policy

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costs and what he charged the 17-year-old.

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What's more, the insurance policy would be worthless,

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leaving the 17-year-old uncovered.

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In the worst-case scenario,

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someone who's been a victim of a ghost broker can be driving around

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in a vehicle, thinking that they're actually insured,

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when the policy has been cancelled and they're driving uninsured.

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Back at the start of 2013,

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LV started to get suspicious that they were being targeted by a ghost

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broker. They noticed some startling similarities in the details

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of some of their motor insurance policies.

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There were some key factors that linked these policies together.

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These were the use of bank accounts and foreign cards which had been

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compromised and also e-mail addresses

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and a common occupation of accountancy.

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During the investigations into the e-mail addresses and bank accounts

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that had been used on several different policies,

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one name kept cropping up - a Mr Abdulatif.

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At first, LV were only suspicious about a few motor policies,

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but once they knew what and who to look for,

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the scale of the fraud escalated.

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Originally, this started off as three policies,

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but it very quickly grew and it was, in fact, the fastest-growing

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fraud ring in LV's history, until it reached nearly 700 policies.

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With suspected fraud on a level this vast,

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LV got in touch with IFED.

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IFED is the City of London Police's

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Insurance Fraud Enforcement Department -

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a dedicated team of detectives

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committed to stopping insurance fraud cheats.

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There is ever-more sophisticated

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detection tools being used by the industry.

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We're getting more and more cases every day.

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This elite squad has prevented millions of pounds from being paid

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out to criminals in fraudulent claims.

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From now on, insurance cheats need to look over their shoulders.

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It's all fraud, it's all crime and it can all lead to prison.

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Police, don't move, stay where you are!

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Police Sergeant Steven Holland works for IFED.

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Once the team took up the case of the suspected ghost broker,

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their first port of call

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was to start investigating the prime suspect...

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..Mr Abdulatif.

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The initial investigation starts

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with some financial investigation work which highlighted that

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Mr Abdulatif is earning money through illegitimate sources,

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we believe. He stated his occupation was a trainee estate agent

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and also a courier. However, we've identified £80,000-plus

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of money going to the account that couldn't be accounted for.

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They also undertook a social networking search

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and were utterly astonished at what they found.

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Mr Abdulatif was enjoying luxuries well beyond the means of a trainee

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estate agent. He'd posted countless

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photos of himself all over his social media pages,

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flaunting his wealth and expensive tastes.

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It shows Mr Abdulatif living a champagne lifestyle.

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Exotic foreign holidays.

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Exotic cars.

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Something that we wouldn't put together with

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a trainee estate agent's salary.

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Everything indicated towards us that Mr Abdulatif was involved in the

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ghost broking and he was our initial and only suspect.

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If this wasn't proof enough,

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the investigation uncovered further undeniable evidence

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that Mr Abdulatif was, indeed, a ghost broker.

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We found over 100 text messages, in relation to offering and asking

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to supply fraudulent insurance.

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We also seized a laptop and, within that, we found several insurance

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companies, certificates of insurance, which he was obviously

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doctoring to provide to the people who were buying the insurance

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policies, but they were all fraudulent.

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And a lot of unsuspecting people

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were buying their car insurance through

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this particularly showy fraudster.

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Mr Abdulatif was making money through either selling

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fraudulent insurance policies

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to members of the public and they would pay him and that money

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would go into his own bank account,

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or alternatively, he was phoning the insurance companies directly

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and paying for these policies with compromised bank cards

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or compromised bank account details.

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The policies paid for by these fake or fraudulently-acquired bank cards

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would quickly be cancelled by the insurance company,

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but of course, Abdulatif wouldn't tell his clients this,

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so many were driving around totally unaware that they had

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no car insurance whatsoever.

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If one of these fraudulent insurance policyholders were in an accident,

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unfortunately, their policy would be worthless.

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Mr Abdulatif took advantage of innocent members of the public

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who paid him for their car insurance,

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but ended up with either no motor policy, at all,

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or a totally-invalid insurance policy.

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But this wasn't as low as this greedy fraudster would go.

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Mr Abdulatif realised that he could make even more money by selling

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insurance to the otherwise uninsurable.

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Mr Abdulatif was selling these policies to either genuine members

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of the public who thought they were buying insurance,

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but we also noticed a proportion of these policies going to known

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criminals and to criminals who had either been disqualified from

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driving, for offences such as drink-driving, or totting up points

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for things like no insurance.

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That's right.

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Thanks to Mr Abdulatif,

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banned drunk drivers were getting back behind the wheel.

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To provide these disqualified drivers with motor policies,

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he would simply forget to tell the insurance company that these people

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had convictions, in the hope they wouldn't check.

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But they did.

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Despite thinking he was untouchable, the police arrested Mr Abdulatif.

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And in October 2015, he was tried at the Old Bailey.

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We had a really strong case with all the evidence that we seized and that

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we went through and it showed

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Mr Abdulatif provided fraudulent insurance policies

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to various members of the public.

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Mr Abdulatif pleaded guilty to 18 charges of fraud.

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He had made over £100,000 from his criminal activities.

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Abdulatif was sentenced to three years behind bars and given

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a confiscation order,

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meaning that almost all of the money will be recovered.

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Still to come...

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A cyclist has a lucky escape, after colliding with not one,

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but two large metal objects.

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The cyclist has flown around the outside. He's just tried to get

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through this gap. There's no way he's going to get through that.

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True enough, he doesn't get through.

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And a woman lands herself in hot water, when her claim for a leak

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goes down the pan.

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Now, on our busy city centre roads there is a constant battle between

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cyclists and buses.

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Bus drivers say cyclists take unnecessary risks,

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and cyclists are adamant that bus drivers are not vigilant enough

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behind the wheel. One thing is for certain, though -

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when collisions DO happen between a 20-tonne bus and a bike,

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there is no contest about who comes off worse.

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And tragically, according to the latest figures,

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around 3,500 people are seriously injured or killed every year

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on their bikes.

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Lee Ingram works as a claims team manager for FirstGroup

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and it's his job to make sure that if any one of his fleet of over

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6,000 buses cause an injury or an accident,

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the right people get compensated.

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FirstGroup run many buses around the country,

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covering a lot of distance on a lot of different types of roads.

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Naturally, in busy city centres,

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we also share those roads with not just other vehicles,

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but with pedestrians and cyclists.

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Lee dealt with one case in a town centre, where a cyclist

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was knocked off his bike by a bus.

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In this case, fortunately, it wasn't fatal,

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but it was quite a serious accident that we had to investigate.

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The claimant in this particular instance was alleging that he was

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travelling in a designated lane.

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He was turning right at a box junction,

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and one of our buses had come from behind him

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and, as it was passing him,

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it has clipped his arm, forcing him to careen off the bus.

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Unfortunately, there's an electrical junction box ahead of him

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and he smashed into this junction box.

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So, he's been unfortunate enough to be hit by a bus

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and then he's been forced into an immovable metal object.

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A serious accident.

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And, as expected, the unfortunate cyclist claimed to have sustained

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a number of injuries.

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So, he's suffered some cuts to his hands, injured his wrist, his arms,

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his shoulders, his neck, his lower back, he's got headaches.

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The trauma of being hit by a bus or shunted into this object,

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has caused him to have flashbacks, insomnia.

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He's claiming a temporary loss of vision.

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So, a wide range of injuries,

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valuing at probably around £15,000 to £20,000

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worth of damages on his claim alone.

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Given the gravity of the incident,

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the first thing Lee and his team did was to speak to the witnesses.

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And, you guessed it, there was a busload of them.

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You've got the driver.

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Obviously, you've got to question what they've done.

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Remember, this is a bus carrying passengers -

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always guaranteed to have plenty of witnesses.

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So, every single one of those we're going to want to check,

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to see if their version of events

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matches with the claimant's version of events.

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And in this case, they didn't. The passengers' accounts of what

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happened put a huge dent in the cyclist's story.

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They felt the driver of the bus

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was driving in a perfectly-normal manner.

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No evidence that he was driving too fast.

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In comparison to that, they did feel that the cyclist

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was going way too fast for the conditions.

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Certainly trying to squeeze through a gap, just as the bus has started

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moving forward and the witnesses themselves did actually feel

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that the cyclist was responsible for the collision.

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With these differing accounts,

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Lee and his team focused in on the CCTV cameras fitted on the bus.

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And the footage confirmed the witnesses' version of events,

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NOT the cyclist's.

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It showed the cyclist speeding alongside the bus.

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It turns right and then attempts to squeeze past through a tiny gap

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between the bus and the curb.

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The cyclist has flown around the outside

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and there's no way he can see ahead of him.

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He's just tried to get through this gap.

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There's no way he's going to get through that, and true enough,

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he doesn't get through that.

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It is a nerve-racking watch,

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as the CCTV footage captures the moment of impact.

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Keep your eye on the top right-hand corner of the screen.

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It was clear that it was the cyclist's own reckless actions

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that caused him to crash into the electrical box.

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This guy could have been horrendously injured.

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If he'd gone under that bus, his injuries could have been

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very serious, if not fatal.

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And all from an accident that could have easily been avoided.

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For Lee and his team, the CCTV evidence brought the cyclist's claim

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crashing to the ground.

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We promptly went back to his solicitors and said,

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"We're not paying this claim, for these reasons.

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"We don't think we were at fault.

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"Your client obviously put themselves in a position of danger"

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and we never heard back from them.

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This was a nasty accident

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and the collision with the electrical box must have been

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particularly shocking for the cyclist,

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who was lucky not to have suffered any serious injuries.

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However, in this case, the cyclist had to take responsibility.

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There can be conflict sometimes between cyclists and users of large

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vehicles. Maybe there just needs to be a bit of tolerance between road

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users, particularly cyclists and other vehicles,

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to avoid far more serious events actually happening.

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Family heirlooms are priceless.

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Really, there's no insurance cover in the world that can account for

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the sentimental value attached to items that have been handed down

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through the generations. But of course, if something has

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a financial value to it, as well as a sentimental one,

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it makes perfect sense to make sure

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it's included in your household insurance.

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Companies like RSA provide exactly this sort of protection.

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John Beadle heads up their counter-fraud department

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and previously dealt with a customer who had taken out contents insurance

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on her home.

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This particular lady took out a household policy with us

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and one of the specified items on

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her policy for all-risk cover was an

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emerald ring,

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valued at £11,650.

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So, an expensive piece of jewellery,

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which also had a rich family history,

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making it all the more valuable to the claimant.

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The ring actually had come from her grandmother,

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who had, in turn, been given it by her grandfather,

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who had bought it for his wife when he came back from India.

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A lovely little gem of a story, but it wasn't to have a happy ending.

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A very short time after she took the policy out, she made a claim,

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saying that the ring had slipped off her finger

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and got lost while she was gardening.

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Now, I've heard of having green fingers,

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but wearing your grandma's emerald ring, worth over 11 grand,

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whilst doing a spot of weeding seemed unlikely.

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John and his team weren't altogether convinced by the granddaughter's

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story, and asked her for further information.

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She provided to us some photographs of her wearing the ring,

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which, in itself, was quite curious,

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the way the photographs had almost been purposefully done to show

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the ring, and she produced a valuation for the ring,

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which had actually only just been obtained

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a relatively short while beforehand.

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Something just wasn't ringing true about the story of the lost piece

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-of jewellery.

-I think there were a number of factors

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that conspired together to make us suspicious of this claim.

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The loss occurring so shortly after the policy had been taken out,

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the photographs, the recent evaluation which had been obtained,

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all added up to make us a little suspicious around the claim,

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so we decided to investigate further.

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And where better to get a few pearls of wisdom about the case than from

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the original owner of the ring, the claimant's grandmother?

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We spoke to the grandmother, who actually confirmed to us

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that the ring belonged to her,

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and hadn't been gifted to her granddaughter.

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And, in fact, the ring was still in the possession of the grandmother.

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She told us that the ring she hid in a secret place in her bedroom.

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The plot thickens.

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The ring wasn't lost, at all, but safe and sound in granny's house.

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However, there was another mystery to solve.

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Strangely enough, she did notice the ring missing recently,

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for a relatively short period,

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but the ring then reappeared back in its hiding place.

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Very few people knew where granny hid her precious emerald ring.

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Conveniently, her granddaughter did.

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To John and his team, it was obvious

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what their gold-digging customer had been up to.

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The claimant had removed the ring

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from her grandmother's hiding place...

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..taken photos of it on her finger...

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..and took a policy out with us

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with the specific aim of making a claim for

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the ring. Then, put the ring back where she had removed it from,

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in her grandmother's bedroom.

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They confronted their scamming customer with the facts they had

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gleaned from her own relative.

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She did try to withdraw the claim and cancel her policy,

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but the circumstances around this

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were so well thought-out that we decided

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it was a case that we needed to refer to IFED

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and that's what we did.

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IFED were keen to take up the case,

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and soon caught up with the claimant.

0:20:160:20:18

She received a caution...

0:20:180:20:20

..and, ultimately, we have now placed her on

0:20:220:20:25

the insurance fraud register,

0:20:250:20:27

which will cause her problems when she tries to get insurance

0:20:270:20:31

in the future.

0:20:310:20:32

But you'd hope that she was also getting a fair amount of comeuppance

0:20:320:20:36

closer to home.

0:20:360:20:37

I should imagine she's extremely unpopular in her family.

0:20:370:20:41

I mean, this was so premeditated,

0:20:410:20:44

and unbeknown to anybody else in her family,

0:20:440:20:46

she had ultimately embroiled them, in her attempt to obtain

0:20:460:20:52

quite a large amount of money.

0:20:520:20:55

This fraudster's golden plan to make a quick £11,650

0:20:550:21:00

was quickly foiled by John and his team.

0:21:000:21:03

Coming up, a cat owner attempts to defraud her insurers, to pay for

0:21:090:21:13

the treatment of her precious pet's upset tummy.

0:21:130:21:16

As long as insurance policies exist,

0:21:230:21:25

there will always be people out there who try and abuse the system.

0:21:250:21:29

If an insurance company even has an inkling that something isn't quite

0:21:290:21:33

right with a claim, they can refer it up to specialist agents.

0:21:330:21:37

Agents like those employed at I-COG Claims Management,

0:21:390:21:43

whose staff is trained to analyse speech and behaviour patterns,

0:21:430:21:46

in order to expose those claimants

0:21:460:21:48

who may not be telling the whole truth.

0:21:480:21:50

One such claim was recently referred to Claire Mitten,

0:21:520:21:55

I-COG's highly-skilled Operations Director.

0:21:550:21:58

The case involves a man who claimed he'd been the victim of a mugging

0:22:030:22:07

in a park in Glasgow, in which his gold necklace

0:22:070:22:10

had been snatched from around his neck.

0:22:100:22:13

The total of the claim was £750.

0:22:130:22:16

He was claiming for a gold chain

0:22:160:22:18

which had a diamante boxing glove pendant attached to it.

0:22:180:22:21

Before we even got to speak to the insured,

0:22:210:22:23

he had three failed appointments, where he wouldn't answer our calls.

0:22:230:22:27

There were just so many concerns with it that we knew straightaway

0:22:270:22:30

that this was a really interesting claim to deal with.

0:22:300:22:32

It was fourth time lucky,

0:22:320:22:34

as Claire finally got through to the claimant, to get a blow-by-blow

0:22:340:22:37

account of the theft of his boxing-glove necklace.

0:22:370:22:40

Mm-hm.

0:23:000:23:01

Mm-hm.

0:23:050:23:06

Mm-hm.

0:23:100:23:11

So, a dramatic and frightening mugging,

0:23:320:23:35

the sort of attack that can leave its mark on the victim

0:23:350:23:38

both emotionally and physically.

0:23:380:23:40

To Claire, the lack of injuries

0:24:180:24:19

sustained by the claimant seemed unusual

0:24:190:24:22

for an attack this physical,

0:24:220:24:23

and especially given that a fairly thick necklace

0:24:230:24:26

had been pulled off his neck.

0:24:260:24:28

You would have thought that there would be some markings to the neck,

0:24:290:24:33

such as scratchings or bruising to the neck

0:24:330:24:34

where it had been ripped off.

0:24:340:24:36

When somebody has been attacked, more often than not they can

0:24:560:24:59

describe the offenders in great detail,

0:24:590:25:01

because they've been so close to them.

0:25:010:25:03

This insured was not able to give us any description, other than he was

0:25:030:25:07

a well-dressed junkie with yellow skin.

0:25:070:25:10

It seemed odd to Claire that the customer couldn't describe

0:25:100:25:13

his attacker well, but it was what he claimed happened

0:25:130:25:16

immediately after the attack that left his story on the ropes.

0:25:160:25:20

Rather than calling 999 or seeking any sort of help,

0:25:200:25:24

the claimant got into his car

0:25:240:25:25

and drove off to collect his wife from work, as normal.

0:25:250:25:29

The claimant went on to explain that, after he'd picked up his wife,

0:26:050:26:08

they did then go to their local police station,

0:26:080:26:11

to report the incident.

0:26:110:26:12

Even if you lost your chain in the park, rather than had it stolen,

0:26:420:26:46

you would still be given some sort of reference number from the police,

0:26:460:26:48

so this was really alarming.

0:26:480:26:50

The claimant was sticking to his story that he'd not been given

0:27:190:27:22

a crime reference number, but the staff at I-COG have

0:27:220:27:25

an expert knowledge of police systems and this gave Claire

0:27:250:27:29

the upper hand. The gloves were now off, as she challenged

0:27:290:27:32

her opponent further about his alleged written statement.

0:27:320:27:36

When we asked the insured if we were able to contact the police,

0:28:060:28:09

to get a copy of the statement that he made,

0:28:090:28:11

he actually softened his voice. He became very nervous and explained

0:28:110:28:15

that he didn't know what the police would be able to provide us with.

0:28:150:28:19

If you do report an incident like that to the police and you have

0:28:190:28:21

given a statement, then actually those reports and statements

0:28:210:28:24

need to be kept for at least 15 years.

0:28:240:28:26

There was one final inconsistency, in regards to the detail

0:28:270:28:30

of the fight in the park

0:28:300:28:32

that really packed the finishing punch to the validity of the case.

0:28:320:28:36

It was the claimant's wife who had initially rung the insurance company

0:28:370:28:41

to report her husband's mugging. But the version of events she told them

0:28:410:28:45

differed substantially to what the claimant had just told Claire.

0:28:450:28:49

Whether you make a claim that's worth £250 or a claim that is worth

0:29:290:29:33

£1 million, the claim is always going to be investigated

0:29:330:29:35

by the insurance company, and there's no way of thinking that,

0:29:350:29:38

just because it's a low-value claim, it's going to get paid out.

0:29:380:29:41

If it's not right, if the account doesn't add up,

0:29:410:29:44

if the information you've given doesn't add up,

0:29:440:29:46

then it will get investigated further.

0:29:460:29:49

And in this case, the claim didn't add up.

0:29:490:29:51

The inconsistencies and the fact there was no crime reference number

0:30:020:30:06

meant that Claire had no choice

0:30:060:30:07

but to recommend to the insurance company not to pay out a penny

0:30:070:30:11

for the alleged stolen chain.

0:30:110:30:13

Now, it's one of those things that none of us wants to be a victim of -

0:30:210:30:25

coming home to find a burst pipe has flooded your house.

0:30:250:30:28

Even a small leak can cost thousands.

0:30:280:30:32

And if you don't have the right insurance,

0:30:320:30:34

you'll be the one soaking up the costs.

0:30:340:30:37

David Berry is the Technical Fraud Manager for Lloyd's Bank Group.

0:30:370:30:40

His team recently dealt with a claim from a customer

0:30:400:30:43

with a home contents policy.

0:30:430:30:45

She called us on the 30th of October and reported to us that when she had

0:30:470:30:51

returned home after being out for most of the day,

0:30:510:30:53

she saw water pouring in through the ceiling in her bedroom.

0:30:530:30:56

According to the customer, the damage was extensive.

0:31:140:31:17

David recalls all the items that the customer was claiming for

0:31:250:31:29

and it's quite the list.

0:31:290:31:30

A mattress, an electric blanket,

0:31:300:31:32

the carpeting, the decorations in the room,

0:31:320:31:35

an iron. There was a hairdryer in the room as well and also a laptop.

0:31:350:31:39

All of those items were damaged by the water that was coming

0:31:390:31:42

through the ceiling.

0:31:420:31:43

The value of the claim was estimated at £2,200.

0:31:440:31:48

On closer inspection, it emerged that the policy had been taken out

0:31:480:31:52

only two weeks before the claim.

0:31:520:31:54

It's not unusual for customers to suffer losses so close to when

0:31:550:31:59

the policy's taken out, but it can occasionally raise some concerns,

0:31:590:32:04

particularly given the nature of the type of loss that's presented.

0:32:040:32:07

As part of the standard process,

0:32:080:32:10

the claims handler asked the customer to provide evidence

0:32:100:32:13

of the damage the leak has caused.

0:32:130:32:15

The customer obliged, and sent in photographs.

0:32:280:32:30

But little did she know these would end up sinking her claim.

0:32:300:32:35

When she produced that information,

0:32:350:32:36

we identified, from the properties within the digital photographs,

0:32:360:32:41

that they were actually taken in September.

0:32:410:32:44

A month before she claimed the leak had occurred.

0:32:440:32:46

Our customer couldn't explain that to us, and as a result,

0:32:470:32:50

we declined the claim on the grounds of fraud and cancelled the policy.

0:32:500:32:53

But there was worse to come.

0:32:540:32:56

As fraud had been detected,

0:32:560:32:58

David decided to refer the case up to IFED.

0:32:580:33:00

The police accepted that she had no previous history of, er,

0:33:000:33:05

inappropriate behaviour, no previous convictions or similar.

0:33:050:33:08

As a result, they felt it was appropriate to deal with the matter

0:33:080:33:11

by way of a police caution.

0:33:110:33:12

IFED may have been lenient in this case,

0:33:120:33:15

but the customer now has a criminal record.

0:33:150:33:19

If you're going to try and make a false claim,

0:33:200:33:22

you'd better make sure you have a watertight cover story.

0:33:220:33:26

Lloyds Bank insurance take matters of fraud extremely seriously,

0:33:270:33:30

and as a result of that, we hope to protect our honest customers.

0:33:300:33:33

Whether you're a dog lover

0:33:420:33:44

or it's cats that make you weak at the knees,

0:33:440:33:46

if you love animals and have a pet,

0:33:460:33:48

they soon become part of the family.

0:33:480:33:50

Many people get a bit of a shock at the amount vets charge

0:33:500:33:54

for their services. Sadly, there is no NHS for animals.

0:33:540:33:58

Thankfully, though, there are companies,

0:34:000:34:02

like Agria Pet Insurance, that will provide cover for vets' bills.

0:34:020:34:06

Back in 2014,

0:34:060:34:07

Simon Wheeler dealt with a case involving owners who had taken out

0:34:070:34:10

a policy for their Ragdoll cat.

0:34:100:34:13

This rather beautiful breed is renowned for its bright blue eyes

0:34:130:34:17

and affectionate nature.

0:34:170:34:19

CAT MEWS

0:34:190:34:20

The policyholder insured the pet on the 1st of December.

0:34:200:34:24

About 11 days after the policy started,

0:34:240:34:28

we got a notification from the policyholder that their Ragdoll

0:34:280:34:32

had suffered a bout of diarrhoea.

0:34:320:34:35

And we got a notification claim for probably around the £200 mark

0:34:350:34:38

would be coming in.

0:34:380:34:40

The poor moggy had come down with a bad case of the runs

0:34:420:34:46

and the owner had taken it to the vet for treatment.

0:34:460:34:49

The cat's illness may not have been pleasant, but the timing of it was.

0:34:490:34:53

All pet insurers insist on something called an exclusion,

0:34:530:34:57

or waiting period, before you can make a claim for your pet's illness.

0:34:570:35:01

This is to stop people from taking out cover

0:35:010:35:03

the moment they think their pet is sick.

0:35:030:35:06

Luckily, for the owner of this particular kitty,

0:35:070:35:09

the cat's illness started just one day

0:35:090:35:12

after they were allowed to put in the claim.

0:35:120:35:14

At the time that we received the claim,

0:35:160:35:18

the notification for the claim,

0:35:180:35:19

it was just outside the exclusion period for illness.

0:35:190:35:22

The dates all tied up.

0:35:220:35:24

So, to all intents and purposes, it seemed a valid claim.

0:35:240:35:27

The owner must have felt like the cat that got the cream,

0:35:290:35:32

knowing their vets' bill would be covered.

0:35:320:35:35

But as soon as Simon and his team were sent the paperwork,

0:35:350:35:38

they found a problem.

0:35:380:35:39

When we got the claim form,

0:35:420:35:44

we also received the full veterinary history from the vet

0:35:440:35:47

and, when we looked at the veterinary history,

0:35:470:35:50

we noticed the first signs of diarrhoea

0:35:500:35:53

and the first symptoms had been noted on the 4th of December,

0:35:530:35:57

so a long time before the policyholder had told us,

0:35:570:36:01

and certainly in the middle of the exclusion period

0:36:010:36:04

at the start of a policy for illness.

0:36:040:36:06

Simon and his team carefully examined the rest of the paperwork

0:36:070:36:11

and found something that really set the cat amongst the pigeons.

0:36:110:36:15

Not only did the policyholder

0:36:150:36:17

submit the wrong date in their part of the claim form,

0:36:170:36:20

they'd also filled in a date

0:36:200:36:21

on the veterinary part of the claim form

0:36:210:36:23

and put a Post-it note for the vet to say, if possible,

0:36:230:36:27

can you make the date the 11th of December or later,

0:36:270:36:31

otherwise this is unlikely to be covered.

0:36:310:36:34

This one Post-it note led to the entire claim coming unstuck.

0:36:340:36:39

It was blatant fraud.

0:36:390:36:41

The policyholder knew exactly what they were doing.

0:36:410:36:45

They knew that the condition of the diarrhoea wasn't covered,

0:36:450:36:48

that it occurred

0:36:480:36:49

within the exclusion period at the beginning of the policy.

0:36:490:36:51

They then tried to coerce, or persuade, the vet to support them,

0:36:510:36:56

in terms of getting a dishonest claim paid by the insurance company.

0:36:560:37:00

Unsurprisingly, Agria didn't pay out a penny for the treatment

0:37:000:37:04

of this cat's diarrhoea.

0:37:040:37:06

It's very common for vets to talk to us about claims

0:37:060:37:09

and for us to talk to vets about claims, when we receive them.

0:37:090:37:13

In this instance, I think the policyholder

0:37:130:37:16

misjudged just what information would come in with the claim

0:37:160:37:19

and what would be on that information.

0:37:190:37:21

When doctors graduate from medical school,

0:37:290:37:31

they take an oath which states they have a duty to act in the best

0:37:310:37:34

interests of their patients.

0:37:340:37:36

But what if they don't?

0:37:360:37:38

What if a doctor was only motivated by personal gain?

0:37:380:37:42

Well, in America, individuals pay for their medical care,

0:37:420:37:45

so private health care insurance is a must.

0:37:450:37:48

But this can give unscrupulous physicians

0:37:480:37:51

the opportunity to commit fraud.

0:37:510:37:53

New York is renowned as the city that never sleeps

0:37:570:38:01

and its 20 million residents require round-the-clock health care.

0:38:010:38:05

Dr Spiros Paulos was an orthopaedic surgeon.

0:38:050:38:08

These specialists exclusively perform bone

0:38:080:38:10

or muscular-related operations.

0:38:100:38:12

He practised at a high-volume private medical centre

0:38:130:38:16

in New York state.

0:38:160:38:17

Spiros reportedly carried out thousands of surgeries

0:38:210:38:24

between 2006 and 2011,

0:38:240:38:26

and was performing up to and over 20 procedures every single day.

0:38:260:38:31

That's a staggering turnover for one doctor,

0:38:330:38:36

which some might say is an example of a man devoted to his job.

0:38:360:38:40

This couldn't have been further from the truth.

0:38:420:38:45

Dr Spiros Paulos's only devotion was to lining his own pockets.

0:38:470:38:51

He was conducting surgeries and carrying out procedures

0:38:510:38:54

his patients didn't need,

0:38:540:38:56

so he could submit false insurance claims, which would pay out

0:38:560:39:00

in excess of 13 million, over the course of his deception.

0:39:000:39:04

While he didn't directly receive payments from insurers,

0:39:080:39:11

the revenue he generated for the company

0:39:110:39:13

earned him massive pay-outs.

0:39:130:39:15

Paulos falsified medical records for procedures he never performed,

0:39:210:39:25

conducted surgery on patients that didn't need treatment

0:39:250:39:28

and would give patients the wrong operation,

0:39:280:39:31

so he could collect a bigger return from insurers.

0:39:310:39:33

He wasn't just abusing his position and violating a sacred trust

0:39:380:39:42

with these fake operations,

0:39:420:39:43

he was botching the surgery with shocking efficiency

0:39:430:39:47

and putting lives at risk.

0:39:470:39:49

One fragile 76-year-old woman went under his knife

0:39:510:39:54

for what should've been a routine procedure

0:39:540:39:56

to reconstruct her arthritic knee.

0:39:560:39:59

24 hours later, that woman was dead.

0:39:590:40:02

The coroner's report found a blood clot entering her lung

0:40:080:40:11

caused her death.

0:40:110:40:13

It also found that no evidence of any reconstructive knee surgery

0:40:130:40:16

had taken place.

0:40:160:40:18

He'd simply sliced her open and stitched her up,

0:40:180:40:21

so he could submit a claim to insurers.

0:40:210:40:24

He hadn't conducted any actual surgery on her knee.

0:40:240:40:27

But this Big Apple surgeon had bitten off more than he could chew

0:40:320:40:35

and it would be his sheer greed which would expose his lies.

0:40:350:40:39

Other surgeons at his company averaged 30 procedures per month.

0:40:410:40:45

Insurers' records showed Paulos

0:40:450:40:47

was doing nearly as many in a single day.

0:40:470:40:49

Naturally suspicious,

0:40:520:40:53

insurers took a closer look at the billing invoices

0:40:530:40:55

they'd been receiving.

0:40:550:40:57

This revealed he had falsified an alarming amount of documents.

0:40:570:41:01

Deeper investigations into procedures performed on patients

0:41:020:41:05

uncovered unusual amounts of repeated surgeries,

0:41:050:41:08

which didn't make any sense.

0:41:080:41:11

Paulos tried to claim the billing discrepancies

0:41:120:41:15

were a result of clerical error.

0:41:150:41:17

He even tried to blame his wife

0:41:170:41:18

for incorrectly transcribing patient records.

0:41:180:41:22

It would do him no good.

0:41:220:41:24

In July 2011, he was fired from his employer,

0:41:240:41:27

subsequently arrested and charged with one count of health care fraud.

0:41:270:41:31

Between 2006 and 2011,

0:41:350:41:37

it was estimated that Paulos had personally profited

0:41:370:41:40

to the tune of 7.5 million through his sickening scam.

0:41:400:41:44

Under interview, Paulos admitted, from 2008,

0:41:500:41:53

after only two years in the job,

0:41:530:41:55

he falsified records almost every time he performed surgery.

0:41:550:41:59

Paulos pleaded guilty to healthcare fraud

0:42:020:42:04

at White Plains Federal Court before a packed gallery.

0:42:040:42:07

Proceedings were watched

0:42:080:42:09

by a handful of patients he had unnecessarily operated on.

0:42:090:42:13

During the trial, Paulos read a statement to the court...

0:42:140:42:17

"I wish I could tell you I had noble motives for this, but I do not.

0:42:170:42:22

"I did this out of greed and insecurity."

0:42:220:42:25

He was sentenced to 4.5 years behind bars

0:42:280:42:31

and ordered to pay costs of 5.5 million

0:42:310:42:33

to the insurers he had defrauded.

0:42:330:42:36

But the criminal trial was just the beginning.

0:42:370:42:40

Now that he's been convicted, some 260 of his ex-patients

0:42:410:42:45

are bringing individual lawsuits against him

0:42:450:42:48

for all manner of abuses suffered under the knife

0:42:480:42:51

of Dr Paulos.

0:42:510:42:52

From organised criminal gangs to exaggerated household claims,

0:43:000:43:04

insurance fraud hits all of us in the pocket.

0:43:040:43:07

But instead of getting away with it,

0:43:070:43:09

more and more of these fraudsters are being claimed and shamed.

0:43:090:43:14

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