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Red Flags to Watch for in Workers’ Compensation Claims

There are many warning signs that Workers’ Compensation claims could potentially be fraudulent. We’ve compiled a list of things to look out for to help distinguish between legitimate claims and potentially fraudulent cases:

The Injured Worker

  • Worker is new on the job.
  • Worker sees doctor first then reports an injury.
  • Worker has a history of short-term employment – nomadic.
  • Worker has a history of reporting subjective
  • There is immediate attorney involvement.
  • Attorney seems to represent suspect workers.
  • Worker seems very familiar with the work comp system – too familiar.
  • Layoffs are pending.
  • Worker is involved with seasonal work that is about to end.
  • Injury occurs prior to a strike or near the end of a probationary period.
  • Worker has also applied for medical and/or disability benefits.
  • Takes more time off than the claimed injury seems to warrant.
  • Experiencing financial difficulties.
  • Changes physician when a release for work has been issued.
  • Rehab report describes the worker in a manner inconsistent with claimed incapacity, including being muscular, well tanned, callused hands, grease under the fingernails, etc.
  • Worker is disgruntled or a problem employee, has recently been disciplined, demoted, or passed over for promotion.
  • Worker took unexplained or excessive time off prior to the claimed injury.
  • Income from work comp and other collateral sources meet or exceed wages after taxes.

Circumstances of the Accident

  • Incident is not reported right away.
  • Claimant is injured at an odd time (lunch hour, before normal working hours, after return from weekend/holiday/vacation, Monday morning or Friday afternoon, away from the job site.
  • Accident occurs after worker was denied vacation/personal time off.
  • Accident is not witnessed, or witnesses contradict worker’s version of story.
  • Fellow workers report rumors that accident was not legitimate.
  • Worker’s family knows nothing about the claim.
  • Accident is unusual for claimant’s normal job duties.
  • Details of the accident are vague or contradictory.
  • Social security number does not belong to worker.
  • Surveillance or “tip” reveals the totally disabled worker is currently employed elsewhere.
  • Medical history chart contrasts with Employer’s First Report of Injury.
  • After injury, worker is never home or spouse/relative answering phone tends to be vague or illusive and states the worker “just stepped out” and will call back (but never does).

Medical Treatment

  • Treatment for injuries is protracted even though the accident is minor.
  • Diagnosis is inconsistent with treatment.
  • Physician is known for handling suspicious claims
  • Worker protests about returning to work and never seems to improve.
  • Workers’ compensation insurer and health carrier are billed simultaneously.
  • Injuries are subjective (i.e.: pain, headaches, nausea, inability to sleep, etc.).
  • Worker cancels or fails to keep doctor appointments.
  • Worker reports treatment and medical diagnosis that is different from Doctor.
  • Worker refuses a diagnostic procedure to confirm an injury.
  • Worker complains of new symptoms just as Doctor is ready to send him back to work.
  • Worker refuses to attend medical exam scheduled by Claims Examiner.
  • Treatment directed to separate facility in which the referring physician has a financial interest, especially if this is not disclosed in advance.
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