Warning signals of workers' compensation fraud

But there are things to look out for to spot potential fraud. Here is a list of some warning signals to help you be on the lookout for abusive claims. Remember, none of these warning signals proves fraud. Discriminating against a worker who has filed previous workers' compensation claims is unlawful, for example. However, the presence of a significant number of these warning signals may indicate that further investigation is warranted.

About the worker

• the injured worker has an unstable work history; i.e., an employee who often changes jobs

• the claimant has a history of reporting subjective injuries which may include workers' compensation or liability claims

• the claimant is consistently uncooperative

• the injured worker has been recently terminated, demoted or passed over for a promotion

• the injured worker is in line for early retirement

• the injured worker is making excessive demands

• the injured worker calls soon after the injury and presses for a quick settlement of the case

• the injured worker moves out of state soon after the injury

• the injured worker changes his or her address to a post office box or receives mail via a friend or relative

About the workplace

• the injured worker's workplace is experiencing labor difficulties; i.e., layoffs, strikes, walkouts, etc., or there are rumors of impending labor difficulties

• the accident occurs just prior to a strike, job termination, layoff, after formal discipline of the employee or near the end of the employee probationary period

• there has been a recent change in the direct supervisor of the injured worker

About the injury

• the injured worker was not injured in the presence of witnesses

• the injury is a subjective one, like stress, emotional trauma, or is hard to prove, like back pain, headache, insomnia, etc.

• the accident is not promptly reported by the employee to a supervisor

• the employers' first notice of the injury is from an attorney or a medical clinic, and not from the injured worker

• physicians who have examined the injured worker have vastly differing opinions regarding the injured worker's disability

• there is no sound medical basis for the disability; all physicians' reports indicate a full recovery

• the injured worker is claiming disability exceeding that which is normally consistent with such an injury

• the accident occurs late Friday afternoon or shortly after the employee reports to work on Monday

• the claimant has the accident at an odd time, such as at lunch hour

• the accident occurs in an area where the injured employee would not normally be

• the task that caused the accident is not the type that the employee should be involved in; i.e., an office worker who is lifting heavy objects on a loading dock

• the details of the accident are vague or contradictory

About the medical relationship

• the claimant frequently changes physicians or medical providers

• the claimant changes physicians when a release for work has been issued

• a review of medical reports provides information that is inconsistent with the appearance or behavior of an injured person; i. e., a rehabilitation report describes the claimant as being muscular, with calloused hands and grease under the fingernails

• the employer's first report of injury contrasts with the description of the accident set forth in the medical history

• the injured worker develops a pattern of missing physician's appointments

About the claim itself or the claimant's attorney

• the injured worker's attorney requests that all checks and correspondence be sent to the attorney's office

• the claimant's attorney is known for handling suspicious claims

• the attorney lien or representation letter is dated the day of the reported accident

• the same doctor/lawyer combination previously known to handle the same kind of injury is handling this claim

• the claimant is unusually familiar with workers' compensation claims-handling procedures and laws

• the claimant's attorney complains to the carrier's CEO at the home office to press for payment

• the claimant initially wants to settle with the insurer but later retains an attorney and files increasingly subjective complaints

• the claimant's attorney threatens further legal action unless a quick settlement is made

• there is a high number of applications from a specific firm

• the claimant's attorney inquires about a settlement or buyout early in the life of the claim

• the claimant writes unsolicited statements about how much better he/she is, but treatment continues and the claimant doesn't return to work

About outside activities

• there are tips from fellow employees, friends, or relatives suggesting that the injured worker is either working or is active in sports

• the injured worker's rehabilitation report shows evidence of other activity

• the injured worker is self-employed or in a trade that would make it possible to otherwise work while collecting compensation

• the injured worker is exaggerating an injury in order to get time off to work on personal interests; i.e., the injured worker is remodeling or building on a home concurrently with the injury

• the injured worker is in a seasonal business that would make it attractive to be injured during the off-season; i.e., occupations in fields such as roofing, landscaping, plumbing, farming, masonry, etc.

• the injured worker leaves different daytime and evening telephone numbers

• the injured worker is never home when called or is always sleeping and can't be disturbed (especially during work hours)

• return calls to the claimant's residence have strange or unexpected background noises that indicate it may not be a residence

• the claimant has several other family members also receiving workers' compensation benefits or other social insurance benefits, such as unemployment