1. Are there any witnesses to the injury, or are the only witnesses the claimant’s “close” co-workers?  (Yet another reason to install security cameras in the workplace.)

  2. Do the claimant and witness statements offer conflicting information?  Do the statements seem rehearsed or even identical?  Do they both contain the same misspelled words?  Perhaps it’s not a coincidence.

  3. Was the report of the injury timely?  Employers should have clear and specific guidelines for reporting work-related injuries.  Supervisors should be trained to bring accidents to the attention of management immediately.

  4. Do the accident report, statements and other documents contain numerous cross-outs, whiteouts, erasures or are they incomplete?

  5. Can the claimant recall specific details about the accident?  (Along with a selective memory loss, many claimants change details of their statement after inconsistencies have been pointed out.  Employers and adjusters should continue to question them on specifics to arrive at what actually happened.)

  6. Is the injured worker a new employee?  Statistically, the newer the employee is, the more likely the claim is fraudulent, especially if other red flags appear.

  7. Does the claimant have a poor attendance record at work?  (Poor attendance records have a funny way of becoming WC claims.  Employers should have a clear and specific attendance policy.)

  8. Does the claimant have a history of discipline issues?  (Along with poor attendance, employees who have discipline problems can become disgruntled employees.  A disgruntled employee has a motive to fabricate the claim.)

  9. Did the accident occur immediately before or after a vacation?  (Employees can become disgruntled when their request for vacation is denied.  Many claimants view time off for a WC injury as a “vacation.”)

  10. Did the accident occur immediately prior to an employee’s retirement?  Often the employee will take an early retirement and may even be moving out of the city or state.  If the employer or adjuster knows the claimant is moving, this information should be relayed to the investigator immediately.

  11. Was the employee injured prior to a strike, company layoff, termination or the employer closing or relocating the business?

  12. Was the employee injured after giving notice?  Nothing says thank you more than an employee who leaves the job and is “injured” during his last few days.  This often happens with employees performing seasonal or temporary work.

  13. Was the employee injured after receiving a disciplinary action, demotion, being passed over for promotion or being placed on probation?  The common denominator is that the claimant is disgruntled.  Again, disgruntled employees are more likely to file fraudulent WC claims.

  14. Does the claimant have problems with workplace relationships?

  15. Did the claimant leave the country for medical treatment? 

  16. Does the claimant have a history of reporting subjective claims or have more than one claim at a time?

  17. Does the claimant’s job history reflect a series of jobs held for relatively short periods of time? This alone should alert employers to potential problems.  Employers can put an end to fraudulent WC claims before they get a chance to start through careful hiring practices.  Investigators can conduct background investigations and verify references and help employers avoid costly hiring mistakes.

  18. Does the claimant’s alleged injury relate to a pre-existing health problem?

  19. Is the claimant involved in hobbies or sports?  Claimants injured playing sports over the weekend often attempt to blame it on a work-related injury early Monday morning.  When claimants are active in sports, this information should be passed on to the investigator.

  20. Is the claimant involved in home improvement or auto repair activities?

  21. Does the claimant have a part-time job that is labor intensive, i.e. building outdoor decks, installing tile, etc.? Many claimants view WC as a vacation of sorts and an opportunity to get some real work accomplished.

  22. Did the injury occur on a Friday but the claimant did not report it until the following Monday, or did the injury happen early Monday morning or at the beginning of a weekly shift?  Probably one of the most common red flags.  This could indicate the claimant was injured over the weekend.

  23. Do the incident report and the medical evaluation offer conflicting information?

  24. Is the claimant refusing or delaying treatment to diagnose the injury?

  25. Does the claimant come to the telephone, or is he sleeping and can’t be disturbed, or is he never home?  Again, one of the most common red flags.  Surveillance should begin early at this claimant’s address.  More than likely he is very active.

  26. Does the claimant miss physical therapy, occupational therapy or other medical appointments?

  27. Does the claimant provide a telephone number but doesn’t live at the address associated with it?  A variation of this is the “message phone,” where the message taker is evasive or ambiguous when asked about the claimant.

  28. Does the claimant provide his friends’, parents’ or other family members’ address or a hotel or post office box?  In other words, the claimant is hiding.

  29. Does the claimant’s family know anything about the claim, or they are extremely helpful to the point of the information sounding rehearsed?

  30. Is the claimant going through a divorce?

  31. Is the claimant going through a child custody battle?

  32. Is the claimant having financial difficulties?  A fraudulent WC claim may be the least of an employer's worries.  This type of claimant is prone to stealing from his employer.

  33. Have you received tips or anonymous information from co-workers, relatives or neighbors suggesting that the claimant’s injuries are exaggerated or not legitimate?

  34. Is the claimant’s lifestyle incompatible with his known income?  These types of claimants have their fingers in all kinds of pies and are usually very active.  Surveillance is a must.

  35. Are the claimant’s family members on workers’ comp or have a history of claims or lawsuits?  A family that “claims” together stays together. 

  36. Are the claimant’s injuries subjective?  This involves soft-tissue injuries, phantom pain, emotional injuries, etc. 

  37. Does the claimant change physicians frequently? This occurs when the physician releases the claimant to return to work or when his diagnosis is at odds with the claimant’s assertions.

  38. Is the claimant healthy, tanned or sunburned?  The claimant is obviously involved in outside activities.

  39. Do the claimant and other workers from the same employer use the same attorney, doctor, chiropractor or clinic?

  40. Is the claimant familiar with claims-handling procedures or workers’ comp rules?  At the very least this could indicate that the claimant has filed a previous claim.

WORKERS COMP RED FLAGS

 

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