Is your workplace safe from Workers’ Compensation Fraud?

Workers Compensation Fraud

As Private Investigators, we investigate potential Workers’ Compensation Fraud claims daily.  Many of these cases are related to the professional fields of trucking transportation, physical labor jobs, and health care jobs.  However, this is only a fraction of the various types of workplace injuries we see related to workers’ compensation claims.

The truth is, any workplace is susceptible to potential employee injuries.  While the risks differ depending on the company and industry, common employee injuries such as repetitive stress, back injuries, and slip and fall injuries do occur in all companies.  The possibility of Workers’ Compensation Fraud to occur when an employee gets injured has been an increasing issue for businesses in recent years.

Potential Fraud Warning Signs

There is no proven method to identifying Workers’ Compensation Fraud, however, there are “red flags” businesses should be aware of:

  1. Monday morning injury reports – The employees injury took place first thing on Monday morning, or occurred at the end of the day on Friday, but not reported until Monday.
  2. No witnesses – No other employees or staff witnessed the accident, and the employee’s description of what happened does not support the injury’s cause.
  3. Treatment is refused – The employee refuses medical treatment to confirm the nature or extent of an injury.
  4. Late reporting – The employee does not report the injury right away and does not give a reason as to why.
  5. Conflicting descriptions – The description of the employee’s accident conflicts with the injury report.
  6. Claimant is hard to reach – The allegedly injured employee does not provide up-to-date contact information, such as residence address and phone number making it difficult to contact them.
  7. History of claims – The employee has a history of related Workers’ Compensation Claims and/or making questionable claims with previous employers.
  8. Suspicious providers – The employee’s medical providers or legal consultants have a history of handling suspicious claims.
  9. Employment change – The reported accident occurs immediately before or after a job termination or layoff.
  10. Changes – The employee has a history of frequently changing physicians, addresses, and/or jobs.

Experience shows that when two or more “red flags” are present in a Workers’ Compensation Claim, there is a chance the claim may be fraudulent. Keep in mind, these are simply indicators.

Typically, employees who are attempting to commit Workers’ Compensation Fraud will usually exaggerate the extent of their injury or simply make them up.  Another instance would be if the employee was injured outside of work, and he/she attempts to report the injury as work-related instead.

Top 5 Injuries

There are many ways an employee can be injured at the workplace. Whether it is negligence or accidental, injuries must be taken seriously. Workers Compensation will vary depending on the severity of the injury.

According to The Travelers Companies, Inc. Injury Impact Report the top injuries sustained in the workplace include:

  1. Strains and sprains comprise 30% of total claims and are the most frequently claimed.
  2. Cuts or punctures are 19% of total claims.
  3. Contusions, or bruises, make up 12% of claims.
  4. Inflammation follows with 5% of total claims.
  5. Fractures are 5% of claims from 2010-2014.

Source: http://www.mhi.org/downloads/industrygroups/ease/travelers-workers-compensation.pdf

If an employer suspects an employee may be committing claim-related fraud, they should report it to their Workers’ Compensation Insurance Carrier immediately.  After notifying your carrier, compile as much information as possible to support the claim. This might include identifying misstatements and witnesses.

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