NSW Investigation on contents claim. What to do?

[Dante12]

We had an incident of theft last year when we were away on a vacation. When we came back all of our portable valuables were gone including jewellery, photography equipment and electronic items. We filed a police report online and lodged an insurance claim. My wife works for the same insurer. They paid her out for jewellery but gave her a tough time during the claim process. She lodged a complaint but in return were contacted by frauds team telling that the police report number was incorrect. Now I will be honest, i didn’t have invoice for a few items which were a gift, I made an invoice. It was a mistake which is why we asked them to cancel the claim and take the money back. They closed the external investigation but they have started internal investigation on my wife and have told her that the invoice was a fake. We have not taken money for electronic items just the jewellery for which we had proof, we even offered to pay them back.

I am just wondering, what will happen now? They won’t find anything against my wife but they know that I made the invoices. Can they take a legal action against us both even though they have closed their external investigation?

They interviewed my wife the other day but they are yet to get back to us.

 

[Zerojay]

Hello Dante12,
There are two sides to this, the attempted claim fraud and your wife’s duty as an employee.
In respect to the claim, the law stipulates that the whole claim may be denied if the attempted fraud is central to acceptance of the claim or affects the majority of the claimed amount. However if the attempted fraud is in respect to only a small portion of the claim then a fairness test should be applied and only the small portion tainted by the fraud should be denied and rest should be accepted. In your case this may mean that only payment for the items on the fake invoice should be denied and you are entitled to be paid for everything else. You say the items on the fake invoice were a gift. Suggest you get a statement or stat dec from the person who gave you the gift as verification. Most likely you cannot now overcome the partial denial but at least proves your loss was genuine and maybe softens the seriousness of your situation.
In respect to your wife’s employment it depends on the level of her complicity in the matter. To help her keep her job, you could provide a stat dec stating that the fake invoice was all your idea and she had no involvement or knowledge of the ruse - if that is the case of course. If she is complicit she could be sacked. She will be at their mercy with right to appeal via the appropriate channel.
I am no expert but I do not see why they would take legal action against you except maybe for return of any money paid to you which you say you have offered to repay anyway.
In respect to the claim only you can appeal to the Financial Ombudsman Service if you are not happy with the final decision of the insurer, but FOS will not take it on if legal proceedings have commenced.
I do not give legal advice, but just an opinion based on working for an insurance company for over 20 years.

 

[Dante12]

Hello Dante12,
There are two sides to this, the attempted claim fraud and your wife’s duty as an employee.
In respect to the claim, the law stipulates that the whole claim may be denied if the attempted fraud is central to acceptance of the claim or affects the majority of the claimed amount. However if the attempted fraud is in respect to only a small portion of the claim then a fairness test should be applied and only the small portion tainted by the fraud should be denied and rest should be accepted. In your case this may mean that only payment for the items on the fake invoice should be denied and you are entitled to be paid for everything else. You say the items on the fake invoice were a gift. Suggest you get a statement or stat dec from the person who gave you the gift as verification. Most likely you cannot now overcome the partial denial but at least proves your loss was genuine and maybe softens the seriousness of your situation.
In respect to your wife’s employment it depends on the level of her complicity in the matter. To help her keep her job, you could provide a stat dec stating that the fake invoice was all your idea and she had no involvement or knowledge of the ruse - if that is the case of course. If she is complicit she could be sacked. She will be at their mercy with right to appeal via the appropriate channel.
I am no expert but I do not see why they would take legal action against you except maybe for return of any money paid to you which you say you have offered to repay anyway.
In respect to the claim only you can appeal to the Financial Ombudsman Service if you are not happy with the final decision of the insurer, but FOS will not take it on if legal proceedings have commenced.
I do not give legal advice, but just an opinion based on working for an insurance company for over 20 years.

Thank you for your response!
Our bad luck, we lodged the police report online and my wife received an email for further information, she missed the email as we were not expecting any response from police via email. The police never attended since on their books we only notified them and did not lodge a full report.

The contents stolen were worth $75,000. They paid us $35,000 and then sent the claim to investigation. We then withdrew the claim. The invoice was worth $10,000.

Unfortunately, the family member who gifted the items is no longer on speaking terms with us. We tried to approach him but he refused to get involved in any way to help us.

Now we are concerned that they may think that the claim is fraudulent hence the legal action. Or maybe take an action against us for that providing that invoice.

 

[Zerojay]

$10000 is a significant amount. I guess you will have to wait and see where the insurance company wants to go with this. Bear in mind, fraud is a criminal offence and one possibility is police involvement. If there is action taken against you, best you get proper legal advice/representation.

 

[DMLegal]

A significant aspect is in what way the invoice was fake - was it one made in Microsoft Word with a random business name, or did it purport to be from a known retailer?