Workers' Compensation Fraud by Employees

Workers’ Compensation Fraud by Employees

insurance fraud

Most employers know too well the importance of workers’ compensation insurance. Should an employee get injured while on the job, the workers’ compensation insurance will take care of the medical bills and the lost wages while he or she recovers. The employee should not be worried about losing a livelihood if he or she reports the injury, meaning there is less incentive to keep quiet about it. In addition, the employer does not need to be worried about negligence lawsuits, as workers’ compensation is the sole remedy for the injured worker against the employer in Pennsylvania. In spite of these benefits associated with workers’ compensation program, there are still some setbacks: one of them being fraud. Below are some examples of how employees can attempt to commit workers’ compensation fraud.  

Employers should be on the lookout for red flags or inconsistencies such as lack of witnesses or injuries that are not medically consistent with the details of what took place. Notable indicators of fraud include injury stories that contradict each other. This can happen when the injured person tells different accounts of what happened to different people, such as medical providers and the workers’ compensation insurance adjuster. It can also take place when witnesses provide accounts that contradict each other, or contradict the account of the injured person. Other red flags are claims and injuries that are reported just before a major change, such as a strike or a seasonal layoff that is likely to result in the employee losing pay.

Some employees may get injured somewhere else or previously, but then go on to claim that the injury took place at the workplace. Such employees may not only file several fraudulent workers’ compensation claims, but may also file fraudulent general liability or automobile claims. All in all, the number of fraudulent claims forms a relatively small percentage of the total number of claims filed. It is unfortunate that such fraudulent claims often lead to payments over a long period. They also result in loss adjustment expenses or claim payments that should not have been paid in the first place. Such claims are likely to take away benefits meant for employees who have been truly injured on the job and who actually deserve the benefits.

In some cases, workers’ compensation fraud may be committed by employees who were actually injured on the workplace; however, these employees then manipulate the system in a way that they get more benefits than they deserve. They may exaggerate their injury symptoms, extend their medical treatment beyond a certain date, or be uncooperative with treatment plans. They may also apply stalling techniques when employers, medical providers or adjusters take positive measures for the claims management process. Claims made by such employees can be very costly, and may deflect payments from those who actually deserve them.

Repeat claims is another red flag for fraud. According to studies, 37% of employees who file a workers’ compensation claim go on to file a successive claim. Repeat claims are certain to trigger fraud alerts, as the workers’ compensation adjusters can run indexes to see if the alleged injured worker has filed previous claims in the past. Once it is discovered that the worker has filed multiple claims in the past, then the attorney for the employer/workers’ compensation carrier can subpoena medical records from past treatment and have a field day on cross-examination of the worker, also known as the claimant in the workers’ compensation litigation.

Legitimate workers’ compensation injuries should definitely be reported by the injured worker, and word to the wise, that individuals who attempt to file fraudulent claims will have to deal with the consequences of tough cross-examination, not to mention, possible criminal charges, as insurance fraud is illegal.