1. Investigators – independent or guns for hire
Investigators – independent or guns for hire? IAATI Training Seminar 2016
19 April 2016
John Price, Lead Ombudsman Insurance, Financial Ombudsman Service Australia

2. Financial Ombudsman Service Australia
Investigators, Loss Adjusters, Forensic Experts, are they truly independent especially if in-house, or are they guns for hire, tasked with achieving a desired outcome for their “boss”?
This session examines the issue of independence through the eyes of the Decision Maker, what they look for in investigation reports – the good, the bad, the ugly.

3. Financial Ombudsman Service Australia
FOS is not a court
It’s an alternative not a substitute
Inquisitorial not adversarial

4. Terms of Reference clause 8.2
What is fair in all the circumstances
Legal principles
Applicable industry codes
Good industry practice
Previous relevant decisions (not binding)

5. Fraud A matter of Intent
The mental element required to establish fraud is an intention to deceive, that is an intention to create a false belief in the person deceived for the purpose of obtaining money or some other benefit
Buchannan JA To v AAMI (2001) 3 VR 279

6. Fraud
Our perceptions, our understanding is shaped by the position from which we start
People are fundamentally honest
The Power of the Paradigm
“A model, theory, perception, a frame of reference”
The way we see things....perception, understanding, interpreting

7. Fraud Mr Justice Young, ALJ 1997 Usual v Unusual Witness consistency
Do not rely on observations of demeanour
Observational evidence needs to be tested
Do not be misled
Cultural Characteristics
Just because a person is shown to be a liar does not establish something is so (e.g. claim to be somewhere but proven not to be does not establish fraud)

8. Fraud - Evidence Character – history Credibility – inconsistencies
Opportunity – timing
Motive – financial, revenge, opportunistic, organised
Experts

9. Questions we regularly have
What happened to transcripts?
Why no interviews with employee/employees?
Where are the financials – especially if an account is involved?
Where are the contemporaneous notes?
What canvas occurred?
Why no police report / statements?
What CCTV / video footage is available?
We don’t want your opinion – we want the facts

10. What we look at Statements – how, when, how long, interpreter?
Record Statements
Police, Fire Dept. records – address these – relevant to time, opportunity etc.
Insurance & Criminal histories – are they accurate?
Observations of demeanour – of little relevance
Has consumer had a chance to clarify? – goes to co-operation
Forensics – proper instruction – what instructions given? – address concerns
Finance is important – Bank Records – should provide – fact that a person has limited income does not mean fraud
Phone Records - provide
Policy documents including PDS, Schedule, Certificate of Insurance – are there issues regarding misrepresentation/non-disclosure?

11. Contact details
FOS Australia GPO Box 3 Melbourne VIC 3001 (Australia) Members contact: Consumers contact: (1800 FOS AUS) or

12. Questions?