Not every claim is fraudulent or exaggerated, but when an employer or insurer notice some of the red flags, they should take a closer look at the claim.
Usually when we take a look at the Claimants level of activity, we uncover information that helps the insurer or employer to close a claim in a favorable manner.
1. Monday Morning Reports: The alleged injury occurs first thing on Monday morning, or the injury occurs late on Friday afternoon but is not reported until Monday.
2. Employment Change: The reported accident occurred immediately before
or after a strike, job termination, layoff, end of a big project, or at the conclusion of seasonal work.
3. Suspicious Providers: An employee’s medical providers or legal consultants have a history of handling suspicious claims, or the same doctors and lawyers are used by groups of claimants.
4. No Witnesses: There are no witnesses to the accident and employee’s own description does not logically support the cause of the injury.
5. Conflicting Descriptions: The employee’s description of the accident conflicts with the medical history or First Report of Injury.
6. History of Claims: The claimant has a history of a number of suspicious or litigated claims.
7. Treatment is Refused: The claimant refuses a diagnostic procedure to confirm the nature or extent of an injury.
8. Late Reporting: The employee delays reporting the claim without a reasonable explanation.
9. Claimant is hard to reach: The allegedly disabled claimant is hard to reach at home.
10. Changes: The claimant has a history of frequently changing physicians, changing addresses and numerous past employment changes.
Experience shows that when two or more of these factors are present in a workers’ compensation claim, there is a chance the claim may be fraudulent. Remember though, that these are simply indicators. Many perfectly legitimate claims are filed on Mondays—and some accidents have no witnesses.
If you suspect workers’ compensation fraud, please contact us
· 1 in 4 Americans think it's okay to defraud insurers
· $4.35 million dollars of insurance premium fraud was discovered in 2009
· Between 2005 and 2009, $25 billion in disability payments were based on fraud
· Workers compensation fraud costs the industry $5 billion annually
· The average household pays $200-$300 extra per year in premiums to offset the cost of fraud