How To Spot Workers Comp Fraud

Workers compensation insurance carriers provide protection for employees in the form

of payments and insurance coverage for those who become injured or ill while on the job. In providing this coverage, insurers perform underwriting, establish premiums, and assume the risk for commercial and personal policies that pay employees for their loss of income and medical costs. Over the years of providing this valuable product, insurers have come to recognize when a claim may be fraudulent. By making everyone more aware of this behavior, there may be a reduction in this sort of activity.

When the medical disability is gone but the claim lingers on

Studies show that almost 25% of claims for lost time on the job are exaggeratedcalled malingering, this is when the employee has not yet returned to work although his or her medical disability is resolved sufficiently to allow the employee to return to work. Reasons for this could be poor communicationthe physician doesnt know enough about the job requirements to realize the employee is recovered enough to resume his or her duties; the employee may deliberately try to delay returning to work; the employer may not be closely managing the event and is not aware of the timeline for return; or there may be other reasons why the length of time off work is dragging on.

Insurance companies report a variety of other ways they have seen attempts to take advantage of the system, such as:

Pretending to be injured: An employee may falsely claim an injury has been sustained in order to make a claim. Or, if truly injured, the employee could be pretending the injury is more severe than it is in reality.

Faking an accident: Sometimes working in cahoots with other employees, workers may set up an elaborate scenario where an on-site accident is arranged for an employer or other workers to discover the injured employee, lending an air of credibility to the situation.

Right injury, wrong place: Employees may claim they were injured on the job, when in actuality they sustained the injury away from work.

Old injury, new claim: Employees may claim that they have suffered an injury at work when in actuality the injury is an old one, sustained away from the job.

Investigate and review claims properly

Workers compensation insurance carriers indicate that employers can save money, on both claim amounts and premiums, by working with their professional insurance agent to investigate accidents promptly and thoroughly and closely manage existing claims. Engaging with injured or ill employees at regular intervals can help encourage employees to keep employers informed of any change in their progress that may impact their return to work, and motivate them to reenter the workplace at the appropriate time.

by: TheresaL.Stromberg

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