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Workers compensation fraud is an issue to make sure you stay on top of. Luckily we are here to help.

INVESTIGATING WORKERS' COMPENSATION FRAUD

 

"I don't care if they get a hundred doctors to examine you. If you say your back is killing you, they can't prove it isn't. That's what we call pain and suffering. And the money you get is tax free."


Walter Matthau to Jack Lemmon in the movie "The Fortune Cookie"

 

A claimant who was collecting more than four hundred dollars a week because of "soft tissue" damage was videotaped driving a tractor from a pole barn to an out-building at a remote corner of his farm property. When he arrived at this destination, he was observed leaping from the tractor. Piled on a sled, which the tractor was towing, were several stacks of logs that the claimant unloaded by himself. As a result of the videotape, the man was ruled physically able and ordered to return to work.

 

Surveillance is the most effective tool that can be used to investigate workers' compensation fraud. With cameras, some small enough to fit on a pair of common eye glasses, audio recorders, actual following of the claimant to undercover techniques, irrefutable evidence can be obtained to authenticate or contradict the claimed injury.

 

A self-insured company faced with an overwhelming number of disability claims from a particular region fought back by implementing a policy that included several days of surveillance on anyone going out on a workers' compensation claim. This included habitual malingers as well as first time claimants. In essence, the company was making a statement to it's employees: "...all medical claims will be scrutinized to ensure validity of the claim".

 

Furthermore, if the employee was going to take off on disability they had better be disabled and have the medical proof to substantiate a prolonged period of absence. In less than two years time the company announced a drop of 66% in "open" workers' compensation claims.

 

It should be noted that deployment of an investigator, or surveillance team, should never be a one-time application as it may take several random observations to ultimately expose a pattern of behavior contrary to what the injured worker's limitations may be.

 

The following list of Red Flags will help expose worker's compensation fraud in your business:

When you telephone him, the claimant is always "sleeping"

and cannot be disturbed;

The claimant refuses diagnostic procedures to confirm the injury;

Date, time and place of accident is unknown;

Claimant's is seen with calluses on his hands and grease under

his fingernails;

Claimant's only injury is "soft tissue" damage;

Claimant can never be reached;

Tips from co-workers about the claimant's activities;

Claimant moved out of state;

There were no witnesses to the accident or injury;

The claimant is in line for early retirement;

Specific details of the injury cannot be recalled;

The injury coincides with proposed layoffs, down-sizing, etc.

 
By identifying fraudulent claims, and obtaining information about the claimant's activities, any or all of the following objectives can be accomplished:


Discover the claimant is not injured;

Uncover co-conspirators within the company;

Obtain evidence of medical fraud;

Gain enough evidence to support a conviction of fraud

in a criminal or civil proceeding;

Ultimately, reduce worker's compensation premiums.