How to Recognize Fraudulent Workers’ Compensation Claims

Workplace injury and illness risks greatly depend on the company and industry. Employee injuries such as slips, trips and falls, back injuries and repetitive stress injuries commonly occur. When an employee becomes injured, there is the potential for workers’ compensation insurance fraud to take place. Workers’ compensation insurance fraud is a serious crime and its hefty expense has the potential to take businesses under.

Claim-related fraud is very common, which is when an employee attempts to gain a workers’ compensation insurance benefit by falsely stating that an injury or illness occurred at work or by exaggerating an existing injury or illness. Committing this type of fraud can result in higher insurance premiums for employers and may ultimately hurt workers who truly become injured on the job. It is important for insurance agents to be able to recognize these claims. 

The Warning Signs

There is no one clear cut answer in identifying claim-related workers’ compensation fraud, but there are several “red flags” you can be on the lookout for:

  • Monday morning injury reports: The alleged injury occurs first thing on Monday morning, or late Friday afternoon but not reported until Monday.
  • Changes: The reported accident occurs immediately before or after a job termination, layoff, end of a big project. Or, the claimant has a history of frequently changing physicians, addresses or jobs.
  • Suspicious providers: An employee’s medical providers or legal consultants have a history of handling suspicious claims.
  • No witnesses: There are no witnesses to the accident.
  • Conflicting descriptions: The employee’s description of the accident does not logically support the case or it conflicts with the medical history/injury report.
  • History of claims: The claimant has a history of making suspicious claims.
  • Treatment refusal: The claimant refuses a diagnostic procedure to confirm the nature of the injury.
  • Late reporting: The employee delays reporting the claim without a reasonable explanation.
  • Hard to reach: It’s difficult to contact the allegedly disabled claimant.

When two or more “red flags” exist in a workers’ compensation claim, it’s likely the claim may be fraudulent. However, these are simply indicators. Establish a zero-tolerance policy on fraud and clearly communicate these expectations with clients through written anti-fraud policies. Workers’ compensation fraud is a serious crime that can have a real impact on your professional reputation. By reinforcing policies and expectations and knowing what signals to look for, you can help reduce the likelihood of fraudulent claims.

About AmSuisse

Formed in 2013, AmSuisse, Inc. has quickly distinguished itself as a wholesale operation that specializes in working very closely with our agents and broker partners to develop responsive, individualized service for each client. Our unparalleled writing support, industry-specific expertise, marketing support, responsive proposals and quotes, strong customer service, and strong relationships with our carrier partners have all helped us to provide the best possible coverage for our clients. To learn more about our available coverage, contact us today at (800) 485-0229 to speak with one of our representatives.