Red Flags That May Indicate Workers’ Compensation Fraud

There are certain conditions or behaviors that we commonly see when we investigate fraudulent workers’ compensation claims. Whether they’re intentional attempts or just exaggeration or malingering, both employers and adjusters need to recognize that these “red flags” indicate at least the possibility that fraud may be present and will greatly assist them in conducting a more effective and successful investigation.

Here are some of the signs to look for: 

• The claimant is never home to answer the phone or is “sleeping and can’t be disturbed.”
• The injury coincides with anticipated layoffs or plant closing or is a Monday morning occurrence.
• There are no witnesses.
• Leads from co-workers suggest that your subject is active in other sorts of activities.
• Rehab reports indicate a healthy-looking claimant.
• There’s no organic basis for disability. All indications are that the subject has made a full recovery.
• The claimant receives mail at a post office box and will not divulge the actual address of his/her residence.
• The claimant has a history of self-employment as a tradesman (carpenter, electrician) who might readily work for cash while collecting disability.
• The claimant has moved out of state or out of the country.
• There are excessive demands for compensation.
• The disability is beyond that normally associated with the claimed injury.
• The claimant has a history of malingering.
• There are “dueling doctors.” One says the claimant is disabled, and the other says no.
• There are no witnesses to the injury or the only witnesses are the claimant’s “close” co-workers.
• The claimant and witness statements offer conflicting information.
• The report of the injury is not timely.
• The accident report, statements and other documents are incomplete or contain numerous cross-outs, white out, or erasures.
• The claimant cannot recall specific details about the accident.
• The injured worker is a new employee.
• The claimant has a poor attendance record at work
• The claimant has a history of disciplinary issues.
• The accident occurs immediately before or after a vacation.
• The accident occurs immediately prior to an employee’s retirement.
• The employee is injured prior to a strike, company layoff, termination or the employer closing or relocating the business
• The employee is injured after giving notice
• The employee is injured after receiving a disciplinary action or demotion, being passed over for promotion, or being placed on probation.
• The claimant has problems with workplace relationships.
• The claimant leaves the country for medical treatment.
• The claimant has a history of reporting subjective claims or has more than one claim at a time.
• The claimant’s job history reflects a series of jobs held for relatively short periods of time.
• The claimant’s alleged injury relates to a pre-existing health problem.
• The claimant is involved in hobbies or sports.
• The claimant is involved in home improvement or auto repair activities.
• The claimant has a part-time job that is labor intensive; i.e., building outdoor decks, installing tile, etc.
• The injury occurs on a Friday but is not reported until the following Monday, or the injury happens early Monday morning or at the beginning of a weekly shift.
• The incident report and the medical evaluation offer conflicting information.
• The claimant refuses or delays treatment to diagnose the injury.
• The claimant misses physical therapy, occupational therapy or other medical appointments.
• The claimant provides a telephone number but doesn’t live at the address associated with it.
• The claimant provides his friends, parents or other family members’ address or a hotel.
• The claimant’s family either doesn’t know anything about the claim or they’re extremely helpful to the point of the information sounding rehearsed.
• The claimant is going through a divorce or a child custody battle.
• The claimant is having financial difficulties.
• Tips or anonymous information from co-workers, relatives or neighbors suggest that the claimant’s injuries are exaggerated or not legitimate.
• The claimant’s lifestyle is incompatible with his known income.
• The claimant’s family members are on workers’ comp or have a history of claims or lawsuits.
• The claimant’s injuries are subjective.
• The claimant changes physicians frequently.
• The claimant is healthy, tanned or sunburned.
• The claimant and other workers from the same employer use the same attorney, doctor, chiropractor or clinic.
• The claimant is familiar with claims-handling procedures or workers’ compensation rules. 

To learn more or find out if your suspicions are right, don’t hesitate to contact us at Global Intelligence Consultants, Inc.!