ANNEX A
The ABI seeks information from its members which
fall into the following description, which has been based around
the Fraud Act 2006:
Any party seeking to obtain a benefit under the terms
of any insurance related product, service or activity can be shown,
on a balance of probabilities, through its actions, to have made
or attempted to make a gain or induced or attempted to induce
a loss by intentionally and dishonestly:
· Making
a false representation, and/or
· Failing to
disclose information, and/or
· Having abused
the relevant party's position.
And, one or more of the following outcomes has taken
place which relates to the fraudulent act:
· An
insurance policy application has been refused
· An insurance
policy or contract has been voided, terminated or cancelled
· A claim under
an insurance policy has been repudiated
· A successful
prosecution for fraud, the tort of deceit or contempt of court
has been brought
· The relevant
party has formally accepted his/her guilt in relation
to the fraudulent act in question including, but not limited
to, accepting a police caution
· An insurer
has terminated a contract or a non-contracted relationship/recognition
with a supplier or provider
· An insurer
has attempted to stop/recover or refused a payment(s) made in
relation to a transaction
· An insurer
has challenged or demonstrated that a change to standing policy
data was made without the relevant customer's authority
Provided that the relevant party has been notified
that its claim has been repudiated, or relevant policy or contract
voided, terminated, or cancelled, for reasons of fraud and/or
it is in breach of the relevant terms and conditions relating
to fraud within the relevant policy or contract.
The ABI also collects information from its members
relating to cases of Suspected Insurance Fraud.
Where a handler having an actual suspicion
of fraud (eg manual fraud indicator(s), tip off, system generated
"high risk" referral etc) challenges the applicant/claimant
by letter, telephone call or instruction of an investigator etc,
to clarify key information, provide additional information or
documentation etc, and the applicant/claimant subsequently:
· Fails
to provide further documentation or co-operation
· Formally withdraws
the application/claim (by phone, e-mail or letter) without a credible
explanation.
· Allows all
communication with the insurer to lapse despite the insurer's
reasonable attempts to re-establish contact.
· Accepts (without
a credible explanation) either a substantially reduced settlement
offer in respect of a claim, or a substantially increased premium
in respect of an application/renewal (other than in cases where
there has been a careless misrepresentation).
All other gone away claims/applications arising in
the course of normal (i.e. non exceptional) handling do not represent
suspected fraud under this definition. These would include (but
not necessarily be limited to):
· Gone
away/withdrawn claims or applications when no preceding combination
of suspicion and subsequent challenge has occurred.
· Gone away/withdrawn
claims or applications where a "challenge" is applied
to all new claims/applications of a particular class (e.g. Household
accidental damage) as a matter of routine.
· Lapsed quotes,
where no formal application for insurance cover has been made.
| 
