Legal MACT/TP & WCC Claims Investigation: 

The compensations against fatalities and grievous injuries resulting out of road accidents do fall within the provisions of the Motor Vehicle  Act 1988 and the Workmen’s Compensation Act, 1923 in India and the owner / Liability insurers of the vehicles have to comply with the provisions of the law.

• • India Tops the world in road crashes death and injuries. It has 1% of the World’s vehicles but accounts for 11% of all road crash deaths, witnessing 53 road crashes every hour, killing 1 person in 4 minutes.

                           The average single Third-party fatal death claim costs INR 8 to 12 lakhs which the insurance company pays.

• Carried out specifically insurance companies require
• MACT Investigation (Detecting frauds in Motor Third Party Claims) Comprehensive Investigation of MACT claims
• Age / Income proof of Deceased / Claimant Statement
• Police report verification / Criminal record from court & Document verification
• Claimant, Insured, and Driver statement and verification
• RTO Papers verification from RTO like D.L., R.C. Book, Fitness, Permit, etc.
• Handling High-value cases with expert remarks to reduce liability.
• Sting operation for capturing and exposing fraudulent cases.
• Liaising with Regional Transport Authorities for verification of RTO records.
• Liaising with district court officers and collection of criminal documents.
• Liaising with Income Tax officers for verification of ITRs.
• Liaising with Police Authorities for filing police complaints against culprits & internal fraud.
• Any other relevant verification or investigation required by a court of law or insurance company   Got exposure and dealt in various areas viz., Accident Claims (MACT),

Consumer Complaints, Money recovery suits, DRT Cases, Partition suits, Suits for Specific Performance, Workmen’s Compensation matters, and Legal opinions in respect of Properties.

MACT (Motor Accident Claim Tribunal), Statics on Road Accidents, Frauds Claims and Insurers Defense in Court of Law-India, MACT Investigation.

• • MACT claims fraud is a criminal act that occurs when an individual or group knowingly provides false information or conceals relevant information to obtain insurance payouts/ compensation or other benefits.
  • This experienced that 10% to 12% fraud occurs in any insurance claims system. Insurers observed various Modus of Operandi in MACT claims.

1. Vehicle Implant for Hit and Run Death Case Accident- There are syndicates in the market that engage in fraudulent activities by intentionally placing the vehicles in hit-and-run cases. Their goal is to falsely claim the third-party insurance amount from the insurance company.

2. Natural cause of death or other than accident death cases converted into Third-party claims or Personal Accident Claims.

3. Replace of a driver with a valid driving License holder in an accident where the original driver does not hold a valid license.

4. Exaggerate Compensation amount based on Forged, Fraud income proof of deceased.

• • Example (Reference From): https://theprint.in/india/a-multi-crore-insurance-fraud-that-fed-on-poor-cancer-patients-in-haryana/235771/
  •  
  • Modus of Operandi:
  • A Syndicate allegedly identified poor cancer patients, convinced their families, waited for them to die staged their deaths as accidents with the implanted vehicles, and claimed their death claims under respective policies.
  • Syndicate Details:
  • Master Mind(Ex-Employees of Insurance Company had extensive claim handling experiences and in-depth knowledge of internal processes)
  • Record Keeper with Hospitals.
  • Family Members of Cancer Patients.
  • Post Mortem Doctors.
  • Officers at various Police Stations.
  • Hospitals.
  • Insurance Agents.
  • Public Prosecutors.

Few Major MACT Fraud Claims arise:-

1. Vehicle Implant in Hit and Run Accident death or other nature of death.

2. Driver Implant where the actual driver does not have a genuine driving License to drive the accidental vehicle.

3. Exaggerate of MACT compensation amount by producing false income proofs etc.

4. Planting of deceased in accident, where in actual cause of death was by other nature.

5. Concealment of fact for nature and cause of loss or loss location.

6. Driver Swapping.

7. Mapping of Manual Insurance Cover Notes or Manual Proposal Forms manipulated in back dates.

8. Claim filed on Forged Insurance Policy or Insurance Cover Notes.

Insurers Defense in Court of Law:-

1. Insurance Companies have been allowed to take Defense in a court of law for the following:-
2. Use of Vehicle for Hire and Reward does not permit to ply such vehicle.
3. For Organizing racing and speed testing.
4. Use of Transport vehicle not allowed by permit.
5. Driver not holding a valid driving license or have been disqualified for holding such license.
6. The policy is void as the same is obtained by non-disclosure of material facts.
7. MACT Claim Investigation Triggers and Touch Points:-

• Various Insurance companies have set up a separate MACT investigation department. As per their experiences and Vision, they have different sorts of Triggers and Touchpoints for investigation. These triggers and touchpoints are used to statically evaluate the feasibility and performances of triggers from time to time.

Workers Compensation Claims (WCC):

A Workmen Compensation insurance policy is a commercial insurance policy that covers the legal liability of an employer to provide compensation to its workmen in case of their death or accident. Also known as employee compensation insurance or labor insurance, this insurance enables an employer to demonstrate his ability to meet the obligations imposed by the Workmen Compensation Act. It enables the employer to pay the compensation payable under the Workmen Compensation Act of India, which is monitored by the Ministry of Labour & Employment.

We are conducting the following investigation in the WC

• Surveillance uses audio, video, and other types of surveillance to determine whether an individual worker is as injured as they claim.
• Interviews and research Workers compensation investigators may interview colleagues, friends, family, and other individuals to learn whether there is an issue of fraud and, if so, how great.
• Background checks and records research an investigation into worker’s compensation fraud may include checking medical records, employment records, and other records. Private investigators may also run background checks to see whether a worker has filed numerous compensation claims in the past or if the company has a history of misclassifying employees.
  • Evidence Gathering Worker’s compensation investigators can gather evidence if they uncover workers’ compensation insurance fraud. This can help employers and businesses prosecute fraud and cut off workers’ compensation claims that are not legitimate.

• Right of Recovery from Owner to Insurance Company ( Pay and Recover):-

• Insurance Pay and Recovery Activities Subrogation Recovery Investigations
•  
• Liability of the Insurance Company has been made to a third party even if there is no negligence or defense to the insurance company available. Rights have been given to the Insurance Company by way of legal precedents incorporating various provisions to recover the said amount paid to a third party from the owner.

Our Subrogation and recovery investigators provide a sincere solution to the companies or organizations in determining the occurrence of the losses due to the negligence of the third party and insured person. Our Subrogation and recovery investigators provide complete analysis through site evidence and witnesses to determine the loss. Our Subrogation and recovery investigation services have become an effective process to get a wider solution to losses due to negligence of the third party or insured person. Our services help the clients to take action against major fraudulent activities in the Insurance sector.