A fraud investigation by an insurer is for many people a frightening and uncertain experience. You have submitted a claim and suddenly receive notice that your insurer is launching an investigation into the cause or the extent of your claim. The feeling of being treated as a suspect while you are simply entitled to a payout is understandably frustrating. Still, it is important to know that as a policyholder you are protected by clear rules and that the insurer must comply with strict conditions when conducting a fraud investigation.
Why does an insurer initiate a fraud investigation?
Insurers have the right to investigate claims before making a payout. This right flows from the insurance contract and from the law. The insurer wants to establish whether the claim is justified, whether the stated damage matches reality, and whether there is no deception. An insurer may launch a fraud investigation when there are indications that the claim report is incorrect, when the loss amount is unusually high, or when previous irregularities have been found with the same policyholder. The Dutch Association of Insurers (Verbond van Verzekeraars) has issued guidelines that insurers must follow when conducting investigations. These guidelines, laid down in the Code of Conduct for Personal Investigation (Gedragscode Persoonlijk Onderzoek), offer you as a policyholder important protection. Not every insurer always complies with these rules, which makes knowing your rights all the more important.
Types of investigation an insurer may use
A fraud investigation by the insurer can take different forms. The insurer usually starts with a desk investigation, in which the available information and documents are analyzed. If the desk investigation does not provide sufficient clarity, the insurer may move on to a personal investigation.
Desk investigation In a desk investigation, the insurer analyzes the available data without you directly noticing. The insurer checks your claim against policy data, previous claims, public sources, and databases such as the Central Information System (Centraal Informatiesysteem, CIS). This type of investigation is relatively low-threshold and the insurer does not need special permission for it.
Personal investigation
A personal investigation is a much more intrusive step. The insurer may hire a private investigation agency to conduct observations, take interviews, or otherwise collect information about your private life. The Code of Conduct for Personal Investigation (Gedragscode Persoonlijk Onderzoek) sets strict requirements for conducting such an investigation. The insurer may only conduct a personal investigation if the desk investigation has produced insufficient results and if there is a reasonable suspicion of irregularities.
On-site investigation
In some cases, the insurer sends an expert or loss assessor to assess the damage on site. In principle, you are obliged to cooperate, but you have the right to know who is coming, on whose behalf this person is acting, and what the purpose of the visit is.
Your rights during a fraud investigation by the insurer
As a policyholder, you have a number of important rights during a fraud investigation. It is crucial that you know and exercise these rights to protect your position.
Right to information
The insurer is obliged to inform you about the investigation. You are entitled to clarity about the reason for the investigation, the nature of the investigation, and the expected timeline. If the insurer has a personal investigation carried out, you must be informed of this. Leaving the policyholder completely in the dark is not permitted.
Right of access to the file
Under the AVG (GDPR), you have the right to access all personal data the insurer has collected about you. This includes the investigation report, interview notes, observation reports, and any correspondence with third parties. The insurer must respond to your access request within four weeks. This right is particularly valuable, as it allows you to check whether the investigation was conducted properly and whether the insurer’s conclusions are justified.
Right to privacy
The right to privacy is a fundamental right that also applies during a fraud investigation. The insurer may not collect unlimited information about you. The investigation must be proportionate and subsidiary (i.e., less intrusive methods are preferred over intrusive ones such as surveillance). This means the insurer may not collect more data than is strictly necessary.
Right to a fair procedure
The insurer may not draw unilateral conclusions based on incomplete or unreliable evidence. You must be given the opportunity to present your view on the findings of the investigation. If the insurer wishes to take measures based on the investigation, such as rejecting your claim or registering you in the EVR (Extern Verwijzingsregister), you must be heard on the matter.
Code of Conduct for Personal Investigation
The Code of Conduct for Personal Investigation (Gedragscode Persoonlijk Onderzoek) was drawn up by the Dutch Association of Insurers and contains rules that insurers must follow when conducting personal investigations. Among other things, the code requires that a personal investigation may only be carried out after approval by an authorized officer within the insurance company. There must be a clear reason and the investigation must be proportionate.
When the insurer does not comply with the code of conduct, this may have consequences for the
usability of the investigation result. A court may disregard evidence obtained unlawfully. This may result in the insurer lacking sufficient evidence to substantiate the allegation of fraud.
Cooperation with the investigation
Your policy conditions usually include a duty to cooperate. This means you are obliged to cooperate with a reasonable investigation by the insurer. Refusing to cooperate may result in the insurer rejecting your claim. However, the duty to cooperate has limits. You are not obliged to cooperate with an investigation that violates your rights or is disproportionate. During an interview with the insurer’s investigators, you have the right to bring a lawyer or a trusted person. You are not obliged to answer questions that are unrelated to the claim, and you may request to record the interview. It is wise to obtain legal advice in advance on how best to cooperate without harming your position.
What if the fraud investigation was conducted unlawfully?
If you believe that the insurer’s fraud investigation was conducted unlawfully, you have several options. You can file a complaint with the insurer, start proceedings with Kifid (the Dutch Financial Services Complaints Institute), or go to court. Unlawfully obtained evidence can, in certain cases, be excluded, undermining the basis of the accusation. Examples of unlawful investigation include observing a policyholder without a reasonable suspicion of fraud, initiating a personal investigation without first conducting a desk investigation, or collecting data that are not relevant to the investigation. Failing to inform the policyholder about the investigation can also be regarded as unlawful.
Duration of a fraud investigation
A fraud investigation by the insurer can take weeks to months. During the investigation, processing of your claim is usually suspended. This can have major financial consequences, especially if you urgently need the payout to repair damage or compensate for lost income. The insurer is required to complete the investigation within a reasonable period. If the investigation takes unreasonably long, you can formally demand that the insurer make a decision within a specified period.
Common mistakes during a fraud investigation
Many policyholders make mistakes during an insurer’s fraud investigation that unnecessarily weaken their position. The most common mistake is to panic and hastily make statements that may later be used against you. Always take the time to think before you
answer investigators’ questions, and preferably be assisted by a lawyer. Another common mistake is destroying or altering evidence. The insurer will quickly interpret this as an indication of fraud and it can seriously harm your position. Keep all documents, correspondence, and evidence in their original state. Refusing all cooperation is also unwise, as the insurer may use this to reject your claim. The key is to cooperate thoughtfully, knowing your rights and limits.
The influence of social media on the investigation
Insurers increasingly use public information on social media in their investigations. Posts, photos, and check-ins on platforms such as Facebook, Instagram, and LinkedIn can be used by the insurer to verify your statements. For example, if you claim you can no longer work due to an accident but post photos of sporting activities, the insurer may use this as evidence. Be aware of this during an ongoing investigation and realize that everything you share online can potentially be included by the insurer.
After the investigation: possible outcomes
After completing the fraud investigation, the insurer may reach different conclusions. If the investigation reveals no irregularities, the insurer must still process your claim and make payment. If the insurer does find fraud, it may decide to reject the claim, terminate the policy, and register you in the EVR (Extern Verwijzingsregister). In that case, it is crucial to seek legal assistance to challenge the insurer’s burden of proof and conclusions.
State-funded legal aid
Are you worried about the cost of a lawyer? You may qualify for a toevoeging via the Raad voor Rechtsbijstand (the Dutch Legal Aid Board). If your income is below a certain threshold, the government pays most of your lawyer’s costs. You then only pay a limited personal contribution. This way, professional legal help is accessible even if your financial means are limited.
The difference between a regular investigation and a fraud investigation
It is important to know that not every investigation by the insurer is automatically a fraud investigation. For every claim, the insurer performs a standard assessment to determine whether the claim meets the policy conditions and to establish the extent of the damage. This is a regular investigation that takes place with virtually every claim. An insurer’s fraud investigation goes further and is specifically initiated when there are suspicions that the claim report is incorrect.
The difference is relevant because stricter rules apply to the
insurer in a fraud investigation, particularly regarding privacy and proportionality. If the insurer proceeds to a personal investigation, it must comply with the Code of Conduct for Personal Investigation (Gedragscode Persoonlijk Onderzoek). In a regular investigation, these additional safeguards do not apply to the same extent. It is therefore important to establish exactly which type of investigation the insurer is conducting, so you can assess whether the insurer is complying with the applicable rules.
Get help from a specialist
A fraud investigation by your insurer is a serious matter that can have major consequences for your future. Knowing your rights is a first step, but engaging a specialized lawyer offers you the best protection. A lawyer can ensure that the investigation proceeds correctly, that your rights are respected, and that any measures are proportionate. Are you facing a fraud investigation by your insurer and want to know where you stand? Contact us for a no-obligation conversation. We will assess your situation, advise you on your rights and options, and assist you throughout the entire process. The earlier you seek legal help, the stronger your position.
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