Suspicious Workers Compensation Claims

August 20, 2018 No Comments

In today’s economy, some employees may feel compelled to turn in fraudulent workers compensation claims.  In some cases there may exist an economic incentive for employees to try to get their non-work injury covered by workers compensation insurance.  For example, if an employer does not offer health insurance benefits, the employee may feel that the only way they will get their medical bills paid would be to allege their non-work related injury happened at work.

Below are a few controls that you should consider to reduce your chances of having a fraudulent or suspicious workers compensation claim:

  • Remove economic incentives for reporting illegitimate claims.  Provide all employees with health insurance benefits.
  • Thoroughly screen potential new hires and try not to hire people with financial problems, drug problems, alcohol problems, or a history of prior workers compensation claims.
  • Post a supervisor at the punch clock at the start of each shift (especially on Monday mornings) to observe employees as they walk into the plant.  Employees in obvious pain, discomfort, limping etc. should be confronted to determine what’s going on.
  • If you suspect that a new claim may be fraudulent, immediately report your concerns to your workers compensation insurance company.  All major carriers have special procedures that go into effect when they learn of a suspicious claim.
  • Thoroughly investigate, and fully document all of the details and facts of any suspicious incident.
  • Establish procedures that encourage the prompt reporting of on-the-job accidents.  Establish a work rule that says all work related injuries must be reported the same shift in which they happen.  For example, if an employee punches out, leaves the premises, and then reports the accident –  that accident is a “late report” by definition and the employee will be subject to appropriate disciplinary action.

Even with all of the above controls in place, it is still possible to have a fraudulent or suspicious claim.  The following are some indicators that will help you to identify a suspicious claim:

  • The employee had a recent argument with a supervisor
  • The employee has a second job
  • The claim was not reported immediately
  • The claim happened on a Monday morning
  • The claim happened soon after the start of the shift
  • The employee is vague on the details
  • The employee wanted a few days off work; but either did not have the vacation days to use, or was denied permission to take a vacation.
  • Their are differences in the accidents’ details from the employees story and the witness’ story
  • The employee is expecting to be laid off work
  • Anticipated plant closing
  • The employee has extremely physical outside work hobbies (e.g. weight lifting, football)
  • No witnesses to the accident
  • The accident happens in an area the employee does not usually work at
  • The employee is a new employee
  • The injured worker is having financial problems 
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