Whether you’re a business owner or an employee, workers’ compensation is important to every...
Workers' compensation (WC) insurance serves as a vital safety net, offering financial support to employees who suffer on-the-job injuries, covering their medical expenses and wage losses. While most WC claims are legitimate, it's crucial to be aware that a significant number of fraudulent claims, costing billions of dollars annually, infiltrate the system. To help you identify potential instances of WC fraud, we've compiled a comprehensive list of red flags to watch out for:
- Suspicious Timing: The "Monday Morning" or "Late Friday" Scenario
One common indicator of fraud is when an alleged injury miraculously happens either "first thing Monday morning" or conveniently late on a Friday afternoon but mysteriously isn't reported until the beginning of the workweek.
- Employment Events: Coincidences or Calculations?
Be cautious when the reported accident coincides with significant employment events such as strikes, layoffs, the conclusion of major projects, or the end of seasonal work.
- Post-Termination Claims: Raising Eyebrows
If an employee files a workers' compensation claim after being terminated, consider:
Did the employee report the alleged injury before termination?
Did the employee exhaust their unemployment benefits before seeking workers' compensation benefits?
- Frequent Changes: A Pattern Emerges
A claimant with a history of frequently changing physicians, addresses, and places of employment might be a cause for concern.
- Medical History Mirrors Injury: A Pre-existing Condition?
Pay attention if the employee's pre-existing medical condition closely resembles the alleged work injury.
- The Lonely Accident: No Witnesses
An accident with no witnesses and an employee's description that lacks logical support for the cause of injury can raise suspicions.
- Contradictory Accounts: Misaligned Narratives
When the employee's accident description conflicts with their medical history or the First Report of Injury, it's time to dig deeper.
- A History of Claims: A Troubling Pattern
A claimant with a history of numerous suspicious or litigated claims should be thoroughly scrutinized.
- Refusal of Diagnostic Procedures: Hesitation to Confirm
When a claimant refuses a diagnostic procedure that would confirm the nature or extent of an injury, it raises questions.
- Delayed Reporting: Untimely Notifications
If the employee unreasonably delays reporting the claim without a valid explanation, it's worth investigating.
- Elusive Claimants: Hard to Reach
When you encounter difficulty contacting a claimant at their supposed home address while they are allegedly disabled, exercise caution.
- Moonlighting: A Double Life?
Does the employee have another paying job or engage in volunteer work while claiming incapacity?
- Odd Coincidences: Timely Injuries
Be wary of unusual coincidences between the employee's alleged injury date and their sudden need for personal time off.
- Financial Struggles: Borrowing and Advances
Employees attempting to borrow money from co-workers or the company, or those frequently requesting pay advances, should trigger an investigation.
- Risky Hobbies: Parallel to Work Injuries
Consider whether the employee's hobbies could lead to an injury similar to their alleged work-related one.
By staying vigilant and recognizing these warning signs, you can play a pivotal role in safeguarding the integrity of the workers' compensation system. Identifying and addressing fraudulent claims not only protects the resources of employers and insurers but also ensures that genuine claimants receive the support they genuinely deserve.
Did this article help you settle your suspicion of fraud or make you even more confident it was real? If you still have concerns regarding your Workers' Comp Insurance be sure to contact a TPG Specialist at 909.466.7876 today!
Also, do you know how to handle Workers' Compensation Claims for Leased or Temporary Workers? Or, have you heard of these Tips for Teen Workers? Read these articles and more on our blogs/resources page now!
