AOE / COE
(Arising Out of Employment / Course of Employment)
Perez Investigations Inc. has over 32 years of experience handling AOE/COE investigations. Our investigators obtain all necessary information in order to properly evaluate a claim.
AOE/COE is a workers’ compensation investigation conducted to determine the facts surrounding an alleged injury to a worker on the job. The purpose of an AOE/COE investigation is to establish whether the employee’s alleged injury was work-related and happened during the course of employment or whether the injury was non-industrial related. AOE/COE investigations are essential during the early stages of an industrial related claim.
Experienced AOE/COE investigators often times find the possibility of Subrogation whenever applicable and list any contribution factors involved.
The Latin phrase Sub-Rosa means "under the rose" and is used in English to denote secrecy or confidentiality, similar to the Chatham House Rule.
Fast forward to today and the word Sub-Rosa is used to describe surveillance or the secret act of watching a person or group.
A Sub-Rosa Investigation is one of the most powerful tools a claims professional has to build a case and document evidence. What stronger evidence than someone caught on film waterskiing hours before he or she was barely able to walk into a doctor’s or attorney’s office? Video that exposes claimants in unguarded moments will document their true physical limitations.
Our surveillance investigators are trained to handle any situation one may encounter when out in the field. Covert cameras allow our investigators to obtained quality video in tight confined quarters.
Perez Investigations Inc. SIU (Special Investigations Unit) provides specialized investigative and advisory services on moderately complex situations involving questionable, suspect or fraudulent claims activity.
Our SIU investigators will work with law enforcement and other related agencies to investigate potential fraud. Investigators work under limited supervision to perform work assignments and problem resolution. SIU investigators will participate in the development of fraud prevention strategies and independent complete investigations.
- Evaluates claim fact patterns and develops work plans to reconcile issues
- Receives and evaluates information about fraud schemes and trends
- Reviews initial referrals, evaluates claim and underwriting information to identify appropriate assignment level and investigative strategies
- Contributes to the development of any and may present verbal and written investigative and management reports
- Collaborates with team members to resolve issues and to identify appropriate issues for escalation
- Acquires and applies intermediate knowledge of state laws and regulations pertaining to insurance fraud
- Acquires and applies working knowledge of insurance industry products, services & processes to include insurance policy contracts & coverage’s, and claim handling processe & procedures
- Develops and maintains external relationships with industry, law enforcement and other contacts involved in fraud investigation, detection and prevention
- The SIU Specialist will demonstrate integrity, confidentiality, good judgment and solid decision making abilities
- Testify in the related court proceedings
- Provide services to include review of the incoming referrals of suspicious claims, gather all relevant information, strategize the case and develop recommendations for case handling
- Receives entire claim from the claims examiner and conduct initial review and analysis
- Organize the file into the following categories:
- Claim notes/Doc notes
- Red flag checklist
- Transaction summary/medical bills paid
- Medical reports sorted by date and body part
- AME/QME Reports
- Deposition summaries
- Attorneys/Client privilege correspondence
- AOE/COE reports
- Sub-Rosa reports and video