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Submitting a claim? Here’s how we protect you from fraud

Part 2 in our fraud series: Three Wawanesa Insurance Specialists talk about how they help policyholders through the claims process.

Missed part 1? Learn how to spot auto fraud


Our top priority is to keep rates affordable for all of our policyholders and ensure they have the coverage and service they need. 

As a mutual insurance company owned entirely by our policyholders, Wawanesa approaches all reports of new claims as being honest. At the same time, we need to have measures in place to verify all information provided during a claim is factual and accurate.

Here’s how we support our policyholders at the time of a claim, and how our claims teams help you each and every day — sometimes in ways you may not even realize!

Human connections are first and foremost

Adjusters at Wawanesa connect with our policyholders personally by phone – starting with the presumption that the claim details are truthful.

“We trust that most people are making accurate claims for loss or damage to their car or property,” says Elle Leyland, Wawanesa’s Director of Regional Claims – Operations. “We will only open an investigation if the indicators don’t add up; if there’s a lack of documentation, or if some of the information doesn’t make sense based on the thousands of claims we handle every month.”

If something is flagged as suspicious — by our technology, or by a broker or adjuster — we respond immediately. That’s when our Special Investigations Unit (SIU) gets involved.

What is the Special Investigations team looking for?

The team helps to determine if the damages claimed are not truthful. When we encounter a dishonest claim, our policyholders – rightfully – expect that we will not pay it.

2020-10-06-SIU-fraud-protection-quote01-ENStaged vehicle collisions are the worst example of this behaviour and they drive up the cost of premiums. In fact, the Insurance Bureau of Canada reports that insurance fraud costs Canadians more than $1 billion a year in added insurance premiums.

The negative impact can also extend well beyond insurance. Fraud puts unnecessary strain on society including law enforcement, legal and health care services.

“Our biggest concern is fraudulent claims that drive up insurance rates for all Wawanesa policyholders,” says Jim Pletsas, Manager of the SIU with Wawanesa. This isn’t just related to false or exaggerated claims. Policyholders might also unwittingly become victims of fraud by other parties.

“We encounter fraud against customers involved in automobile collisions,” says Pletsas. “Occasionally, we have experienced dishonest behaviours by some towing companies and auto body shops where we have paid thousands of dollars to repair a vehicle, and later learned that they did not repair it properly, or caused unnecessary delays that drive up the cost of the rental car. Once again, policyholders pay for that in terms of higher premiums, so we are trying to catch these before we pay the claims.”

How can you protect yourself?

It’s crucial to be aware of the potential risks and always trust your instincts when you come across unusual behaviour, as it may be a warning sign of attempted fraud.

“Unfortunately, there are cases where an unscrupulous person might wave you through at an intersection and then purposely drive into your vehicle,” explains Pletsas. “From there, that person might allege they didn’t actually give you the go-ahead, and then say that they’re injured and you are at fault.” 

There are proactive steps policyholders can take to protect themselves.

  1. If you are in an accident and the circumstances seem odd or the other driver claims to be injured, call your insurer for guidance – even from the scene of the accident if it is safe to do so.  
  2. At the onset of a claim, speak with your insurance adjuster or broker by phone. As an expert on your side, they can help guide you through the process.
  3. Do not feel pressured to sign forms to get any services until you speak to your  insurer.
  4. Never sign blank forms.

Detecting fraudulent activity

At Wawanesa, we are investing to fight fraud on behalf of our policyholders by combining human experience with advanced technology to detect patterns, anomalies and outliers.

“Our experience is deep, and we’re heavily involved in industry work to fight fraud,” says Rohith Mascarenhas, Director of the Casualty, Legal & Special Investigations Unit with Wawanesa. “We’re not just relying on analytics, but also the manual detection of fraud.”

Mascarenhas further explains the importance of collaboration between policyholders and brokers, within internal teams at Wawanesa and industry wide. “Since fraud is a reality facing all insurers and insureds, it’s necessary to approach fraud prevention together as an industry and a society.”

That means educating staff on emerging patterns and indicators of fraud. “Combine that with analytics and it creates an environment where we can be proactive rather than reactive,” added Pletsas.


Staying a step ahead through advanced technology

As part of this effort to stay on the cutting edge, Wawanesa is a member of the Canadian National Insurance Crime Services (Canatics), an industry consortium that uses “technology to support the fight against auto insurance fraud in Canada.” The organization describes their mission to use “state-of-the-art analytical tools to identify potentially suspicious claims in insurance industry pooled data.” This fraud detection is for the benefit of Canadians and, in turn, can improve road safety.

Analytics and artificial intelligence can help to spot unusual activity, but having an experienced team in place is just as important. “There’s a lot of temptation to automate everything and let it be an AI-driven process,” according to Leyland.

But the human element is critical. When a customer is submitting a claim, “it’s a sudden event, and it’s often an upsetting event,” she says.

Majority of claims are not fraudulent

If an adjuster or our systems call attention to a claim that requires additional review, the SIU team will review to see if there’s a need for further investigation.

“The claims we investigate are for very compelling reasons, based on our years of experience in paying valid claims. The SIU gives our company the ability to look at the claim through different lenses,” says Pletsas.

With years of experience and the aid of technological tools, referrals are assessed to find the few that warrant investigation.

“We don’t investigate claims that, after our assessment, appear trustworthy,” Pletsas continues. “We may open a case, however most of our investigations are precautionary and do not end up with any determination of fraud or require a denial of payment.”

Focus on protecting the customer

While all insurance companies face the same challenges with fraud, Wawanesa’s model is slightly different than others. “We’re a mutual insurance company, and our focus is on protecting our customers, both from being a victim of fraud and from increasing premiums,” says Leyland. “There is a subtle difference in our approach.”

A stock insurance company, for example, is owned by shareholders and any profits are paid to them.

“We don’t have shareholders and we don’t have to pay any profits to them. So at the end of the day, our goals are different from many other insurance companies,” says Leyland. “We work for our policyholders. We want to make sure we’re paying honest and the right claims, which is benefits all policyholders.”

Making your claims experience more positive

Wawanesa sells and distributes its insurance products through a network of about 1,000 brokers across Canada. These experienced professionals live in their communities alongside customers — and they’re the ones who can help a customer choose the best insurance product for their needs.

The broker’s relationship with Wawanesa can help the customer in the event of fraud, since the broker has access to Wawanesa’s team, experience and processes.

“Everything we do is to benefit our policyholders and to make the process better for them,” says Leyland. “Fraud is not a victimless crime. For Wawanesa it is about people helping people.”

Read part 1: Could you be a victim of auto fraud (and not even know it)?

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