How Are Workers Compensation Fraud Cases Determined?

Premiums for worker’s compensation insurance have more than doubled on a nationwide average, causing insurance companies to be much more discerning when it comes to accepting worker’s compensation claims. The number of workers compensation fraud cases has caused growing concern, often delaying the processing of legitimate claims. This can lead to honestly injured workers who need assistance with their medical expenses having their compensation delayed, or even dismissed in some cases. Fortunately for both employers and honest employees, there are signs that insurance companies use to determine whether a certain claim is fraudulent as opposed to valid.

Timing of Initial Report

Typically, when an honest employee is injured, the occurrence will be reported to an employer immediately, to have the cost of treatment relieved as quickly as possible. Someone who may be filing a fraudulent claim would have to wait a period of time from the “incident” to report the occurrence, mainly because they cannot readily prove the injury happened. This doesn’t mean all employees who file late claims are committing fraud, but this circumstance will cause claim adjusters to examine the claim as closely as possible.

Details and Documentation

In an honest worker compensation claim, the claimant generally will not hesitate to produce any documentation asked for by the claim adjuster.

Details of the injury are clear and present, whereas claimants in fraudulent cases tend to wash out or dilute as many details as possible to avoid being caught in and story discrepancies.
Also, generally in a worker compensation claim there are witnesses to the accident or injury who have no reason to be weary of giving a detailed report to what they witnessed.
If the claimant cannot produce a reliable witness, this in most cases will signal that something is off.

Personal Details of the Employee

Generally an insurance claim adjuster will look into the claimant’s criminal history, trying to establish prior occurrences of fraud charges or criminal behavior that would otherwise signal the claim itself may be suspect. If the employee has an outstanding debt of any significance, or is experiencing financial hardships, these are all indicators that the employee has been pushed to try and make money to cover expenses by defrauding the insurance company.

Means of Determination

Insurance companies will use virtually any resource at their disposal to uncover a fraudulent worker compensation claim. Many agencies have their own in-house investigation staff, while others hire out independent professionals. These individuals perform credit checks, surveillance, even interviews with prospective witnesses as a means of debunking fraudulent claims. It is through these investigations most fraudulent claims are spotted, while only a fraction of them come from individuals reporting a claim they believe to be a fraud.

Getting Help

If you have been accused of worker's compensation fraud or if you want to ensure your claim does not accidentally get tagged as fraudulent, consult with an experienced worker's compensation attorney. Your attorney can assist you in gathering the appropriate and necessary evidence to prove your claim is legitimate and that you are really entitled to worker's compensation payments.

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