You might be a fraud! Read this article and find out.

Article on Fraud by Edward Singer, Esq. Copyright, 8/3/00

Every once in awhile, one of the Television Networks runs a special undercover expose in which an individual receiving workers’ compensation benefits is caught on tape participating  in compromising activities.  The usual videotape shows the individual doing chores such as chopping wood or shopping, or participating in outdoor activities such as sports. 

The insurance industry often uses indicators to determine whether or not to investigate workers’ compensation claim for fraud.  These indicators are sometimes referred to as “red flags.”   As an injured worker or an individual who assists injured workers, the existence of these red flag situations may lend some light as to how and why a claims administrator is handling the claim in a particular way. 

Advocates of injured workers, however, find some of these “red flag” items to be debatable. 

Here are a number of indicators and responses to them. 

 Employee, who worked for only a short period of time, before claiming injury.   

When someone is new to their job, they are unfamiliar with their setting. Therefore, there is a greater likelihood that the individual will get injured. 

 The alleged injury takes place before a lay-off, strike, job termination, or plant closure. 

When an employee’s employment is ending, an injured worker sees that time as the appropriate time to claim an injury.  There are many reasons.  First, insurance coverage will end.  Second, the employee views this as the last opportunity to make the claim .  Third, the employee has downside for making the claim.  There is no fear of termination or retribution for filing the claim since the employment relationship will be ending.  In sum, at this point in time, there are more incentives for an employee to consider filing a claim.  

 The employee’s history of accident is not credible. 

 Sometimes, an employee, who is not a physician, may not know how they in fact got injured.  A person who develops a cumulative trauma injury, for example carpal tunnel, may not understand the injury process and symptomology.  Therefore, their understanding of what caused the injury and the history of injury may not be accurate.  Many employees in the process of being injured may not be taking notes. 

 There are no witnesses to the claimed injury. 

Many times accidents happen when no one else is around.  In the workplace, there are many jobs for which an individual works alone.  In those situations, there are simply no witnesses. 

 The employee has a history of prior workers’ compensation claims and personal injury claims. 

There are a number of reasons why a person has multiple claims.  Some employers have attendance based policies.  Further, workplace injury absences are not charged against that employee.  Therefore, due to the policy of the company, numerous work injuries are claimed.  Additionally, some companies have policies that every injury must be reported.  Some employees zealously report injuries.  In the past, I have represented an Applicant with over 20 outstanding claims.  Most of them were medical treatment only claims.  Further, with respect to some employees with personal injury claims, some individuals are simply cursed.  They have, unfortunately, been victims of unfortunate circumstances.  Also, employees who have had multiple injuries also have an increased likelihood of aggravating previously injured body parts.  For example, somebody who has a bad back may have it aggravated lifting something at work.  In the legal field, we call those individuals egg-shell plaintiffs. 

 Co-workers state that the employee’s injury is not legitimate. 

Sometimes, statements by co-workers can be misleading.  Practically every Defense Counsel in workers’ compensation has the story of the co-worker denying that the claimant fell off the ladder.  The reason being that when he first saw him, he was already on the ground and the ladder was on the floor.  Further, statements of co-workers may be accurate.  The statement, however, when considering the law in workers’ compensation, in fact, proves that the injury is work-related.  For example,   "this isn't a valid injury, he was clumsy and fell down.  Had he paid attention, he wouldn't have gotten hurt." Such a statement may be true.  Workers' Compensation, however, is a "no fault" system and that injury would most likely be a legitimate claim. 

The employee’s claim is related to a pre-existing problem. 

It is only logical that someone, who has a previously injured body part, stands the likelihood of having it re-injured.  As noted above, this is an egg-shell plaintiff. 

Employee does not report the accident in a timely manner. 

Sometimes, after an injury, an employee may think that the damage was minor and that it would heal.  Sometimes, rather than reporting the injury, they seek medical attention on their own to avoid the hassle of filing a claim when it is anticipated that there will be no residual.  Othertimes, an employee may not be aware that the injury was work-related or be unaware that they can claim the injury as being work-related.  If that occurs, there will be a delay in reporting the injury. 

 The accident occurs on a Monday, or the accident happens on a Friday but is not reported until Monday. 

Again, the same arguments made previously apply to these “red flags.”  Many times a worker who is injured on Friday may think that it is not a big problem.  However, during the course of the weekend the condition progresses to the level that it is necessary to report the injury.  Second, if the business is closed on the weekends, the next time to report the injury is Monday.  Injuries on Mondays may be related to someone returning back to the workplace after a break.  Sometimes the setting may be unfamiliar or since the person is not in the flow of the workweek yet, they may perform the task or duties in an orthodox manner. 

Injured employee consistently uses the same physicians or attorneys to handle their claims. 

This “red flag” I find to be rather insulting.  If an injured employee has found a good attorney or physician who provided competent representation, why should it be considered suspect if he or she returns to those same providers.  If you had an injury and had a doctor who knew your prior medical history and reaction to treatment, wouldn’t that doctor be in the best position to provide treatment for the current injury.  Further, when a lawyer is familiar with a client’s past, including medical history, and legal history concerning prior injuries, isn’t that person in the best position to be able to understand the new injury in relation to the prior claims?  As a practitioner, it is those clients who go to multiple attorneys and multiple physicians who should be suspect.  Sometimes an injured worker will go to other attorneys or physicians and believe that they can get away without revealing their prior history of industrial claims.  These employees, however, are not aware that the claims administrators will do an index search for prior injuries and undoubtedly catch that employee making false representations concerning his or her prior claims. 

Employee is experiencing financial difficulties prior to submitting the claim of injury. 

This indicator is a real head scratcher.  For those in the workers’ compensation system, we all know that it is not a get rich fast scheme.  One has better luck winning the lottery than getting a quick pay-out on a claim. As it is well known to the public, many workers’ compensation cases can take years to resolve. 

 Index bureau inquiry reports many prior claims.  

Many employers require that every industrial injury be reported which then translates into numerous claims.  There are many employees who have up to 20 claims with their employer by virtue of this policy.  The fact that there are many claims may simply mean that the employee was complying with company policy. 

The claimant frequently changes physicians or medical provider.

Many injured workers in the workers’ compensation system experience treatment which is unlike the treatment that one receives when seeking ordinary medical care.  Physician can at times be hesitant toward providing what the worker needs due to the pressures from either the employer or the insurance company.  Frequently, these experiences cause workers to change doctors.  

Accident occurs in an area where injured employee would not normally be.  

It only seem logical that when one is an area in which they would not normally be they may be unfamiliar with the surroundings have therefore have an increased likelihood of being injured.  

Accident is not the type that the employee should be involved in. 

Again, it is only logical that when a worker is doing something unusual, they are at an increased risk of sustaining an injury.  This is especially the case if they are lifting objects.  This commonly occurs when an office or an employee is moving to another location.  

In sum, there are a number of “red flag” indicators which the insurance companies and claims administrators use to determine whether to investigate claims for fraud which may in fact support or lend support to an injured workers’ claim of injury.  Unfortunately, if too many of these indicators are present, the worker may have their claim subject to special investigation.