Workers’ compensation provides employees important financial protection against workplace injuries, but many workers try to take advantage of the program to enjoy paid vacations from working, large financial settlements, or coverage of medical bills for people lacking health insurance.
There are several red flags insurance claims investigators should be looking for when investigating a claim.
The Most Common Red Flags
There are many possible red flags, such as claims made right before an employee’s retirement date or after a worker was given a termination notice. The pattern is clear: Employees about to stop work want to get what they can before they leave.
Six of the top red flags in compensation claims include the following suspicious situations.
1. Untimely Filing of Claims
The top red flag found in workers’ compensation claims is late filing of injury claims. Claimants often file before a holiday or long weekend because they hope to cover the costs of partying or get compensated because they are ineligible for paid time off other jobs.
Suspicious circumstances for filing fraudulent and untimely claims include:
2. Conflicting Witness Reports or No Accident Witnesses
One of the top red flags for insurance company investigators of workers’ comp fraud is when there are no witnesses. It’s amazing how many accidents happen without witnesses, and employers should consider installing security cameras to cut down on fraudulent claims.
Conflicting reports of accidents are often caused by confederates of the claimant supporting the claim and telling a different story than legitimate witnesses. Do witness reports use the same words and sound rehearsed? That indicates possible collusion to defraud an insurance company.
3. Poor Memory of the Details
Accident reports featuring whited-out information, cross-outs, and erasures indicate poor planning on the claimant’s part. Something doesn’t work in the timeline, and the claimant admits to a faulty memory or being fuzzy on the details and might change or amend the report.
Fraudsters usually admit that they can’t remember details after inconsistencies in their reports are uncovered. Employers should endeavor to get all the details into the report by prodding the claimant and any witnesses.
4. Similar Reports of Injury at the Same Company
Investigators should find suspicious the filing of new claims similar to other injury claims filed against the same company in the past. Claimants often coach their friends, and the similarity of accident reports raises a big red flag.
5. Claimant Makes Frequent Claims
Accidents do happen, and the same people do get injured. However, it’s also a good way to scam the system because people aren’t usually fired for having accidents. Any claimant making a second or third claim bears investigation.
6. Claimant Has a Poor Work Record
Claimants who miss a lot of work often end up filing workers’ compensation claims. Those with attitude problems who require frequent warnings and disciplinary action tend to file for workers’ comp at higher rates than employees with good work records.
Hire an Attorney
As an employee, the best policy is to hire an attorney for any worker’s compensation claim that’sbeing challenged. Coincidences happen, and if you are truly injured, the lawyer can clear up issues for the company to compensate for lost wages and pay medical bills even when fraud is not off the table.
Employers and insurers, on the other hand, can look for state-issued information about how to train their employees to uncover false workers’ comp claims. For example, the state of California offers these materials at insurance.ca.gov.
