Special insurance investigations

At PFA, we are focused on preventing illnesses and offering assistance early on in a course of illness to ensure that as few as possible end up on long-term sick leave and become unable to work. However, should this occur to a customer with PFA Occupational Capacity insurance, we will also help with payouts and continued advisory services.

Each year, we process more than 3,200 new claims for reduced occupational capacity and each year we pay out more than DKK 2 billion in insurance benefits to more than 11,500 customers.

PFA is a customer community, and among other things, this means that our customers are part of an insurance community where we show solidarity with each other. Therefore, if we suspect that a payout or request for a payout is not made on a proper basis, we will examine the case in more detail. After all, if we pay out illegitimate benefits/compensations paid to individual customers, this will impact the rest of the customers. 

In most cases, the investigations reveal that there is a natural explanation for why things do not seem to add up. In other cases, the investigations show that the payout was not correct, and it is then adjusted. In a few cases, however, the investigations reveal that insurance fraud has taken place. 

How do we investigate insurance cases when we suspect illegitimate insurance cover/insurance fraud?

When there is a suspicion of insurance fraud or a suspicion that a payout is not being made on a correct basis, then initially we will carry out an additional review of the insurance claim that the customer has sent to PFA together with other available information. For example, this may be municipal case files or medical certificates.

This review typically has one of two outcomes:

• No inconsistencies are found, which means that the case is closed, and the customer is receiving the correct help and compensation.
• There is still a suspicion of irregularities which results in further investigations.

In cases where there is information or circumstances that are unusual, contradictory, unclear or otherwise apparently inconsistent, we will investigate this before the case is concluded. In such cases it is very common for us to ask the customer for further documentation and/or to respond to some additional questions to clarify the matters that do not seem to add up. 

At PFA, we will always take the steps needed based on the present rules and based on what is least intrusive to our customers.

If there is still a suspicion of irregularities, PFA will investigate the matter further using publicly available sources, including Facebook and Instagram. These investigations are only made by a limited group of employees. 

In very rare cases, we will assess whether there is a need for observation of the insured. This is the last resort, and observations are only used where there is a well-founded suspicion that the insured has misrepresented himself or herself or failed to disclose information that is critical to the case. 

The assessment may also include very special circumstances which means that PFA should be reticent about completing personal observations due to medical or ethical considerations. We are very aware that an observation is an intrusive manner of investigation and therefore we will in every instance require a review and approval by a Group executive vice president from PFA’s Executive Board. Personal observations are carried out without the knowledge of the insured and always as unobtrusively as possible for those involved.

If we find that the insured actually has the problems that are stated, then the observation is immediately ended. However, if the observation confirms and strengthens the suspicion, PFA may choose to treat the case as a fraud case or  a case of an illegitimate insurance claim. Based on this, we will then consider whether we should reject or adjust the customer’s insurance payout. Regardless of the outcome, we will always inform the customer after a concluded observation pursuant to the Danish executive order on investigations carried out by insurance companies.

As a customer-owned company, we will always do what we can to ensure fair treatment of all our customers, and we are very attentive to the need to comply with the Danish authorities’ executive order on investigations made by insurance companies, the industry’s code of ethics for the area and other relevant legislation.

What is insurance fraud?

Insurance fraud is when a PFA customer deliberately misrepresents information or keeps silent about information that is critical in assessing whether the insurance payout is legitimate.

Here are a couple of fictitious examples:

• You participate in a marathon race despite having notified your pension insurance company that your back is so bad that you cannot work at all and can only travel short distances using a walker. 
• You notify your pension insurance company that you are only capable of working 10 hours per week, but in reality, you are working 30 hours per week.

By Danish law, insurance fraud is a crime that can be punished either by a fine or imprisonment. The conviction for insurance fraud will also remain on your criminal record for up to five years.