Workers' Compensation Claim "Red Flags"
These "red flags" serve only to alert as to the possibility of fraud. The presence of any one by itself is not necessarily indicative of fraud, it is simply a indicator that further investigation should be performed.
- The injured worker is a new hire or working at a family owned business.
- The Claimant took unexplained or excessive time off prior to claimed injury.
- The alleged injury occurs prior to or just after a strike, layoff, plant closure, job termination, completion of temporary work, or notice of employer relocation.
- Claimant reports an alleged injury immediately following disciplinary action, notice of probation, demotion, or being passed over for promotion.
- Claimant has a history of personal injury, workers' compensation claims, and/or of reporting "subjective" injuries.
- Claimants job history shows many jobs held for fairly short periods of time.
- Claimant uses addresses of friends, family, or post office boxes; has no known permanent address or moves frequently.
- Claimant's family members know nothing about the claim.
- Claimant was experiencing financial difficulties and/or domestic problems prior to submission of claim.
- Claimant has a high-risk activity, such as skydiving, or mountain climbing.
- Lawyer's letter of representation or letter from medical clinic is first notice of claim.
- The lawyer's letter is dated the same day as the reported incident or shortly thereafter.
- There is a repeated pattern of doctor/attorney referrals; the same doctor and attorney work together on a large volume of claims.
- There are no witnesses to the accident, or witnesses to the accident conflict with the Claimant's version or with one another.
- Claimant fails to report the injury in a timely manner.
- Accident or type of injury is unusual for the Claimant's line of work.
- Facts regarding accident are related differently in various medical reports, statements, and employer's first report of injury. The Claimant's version of the accident has inconsistencies.
- Claimant cannot be reached at home during working hours although claims to be disabled from working; or message taker is vague and non-committal. Claimant is otherwise unavailable and elusive.
- Several of Claimant family members are receiving workers' compensation, unemployment, Social Security, welfare, etc.
- Income from workers' compensation and collateral sources (unemployment, Social Security, long-term disability, etc.) meet or exceed wages after taxes.
- Claimant refuses diagnostic procedures to confirm injury, or refuses to attend a scheduled medical exam.
- Claimant's co-workers express opinion that injury is not legitimate.
- Alleged injuries are all subjective; i.e., soft-tissue, pain, and emotional injuries.
- Claimant changes version of accident after learning of inconsistencies: misrepresentation or fabrication by any party.
- Claimant frequently changes physician, or does so after being released to return to work.
- Physical description of Claimant indicates muscular, well-tanned individual, with callused hands, grease under fingernails, or other signs of active work.
- Medical treatment is inconsistent with injuries originally alleged by employee.
- Claimant undergoes excessive treatment for soft tissue injuries.
- Claimant cannot describe either diagnostic tests or treatment for which employer was billed.
- The doctor ordered diagnostic testing that is not necessary to determine extent of Claimant's injury; or, diagnostic testing is performed, yet there is no request by doctor in medical files.
- Diagnostic tests are performed by a vendor not in close proximity to doctor's office or Claimant's home, vendor uses post office boxes on all documents, or cannot supply diagnostic records.
- Doctor or medical clinic has ownership share in diagnostic group.
- Various reports by a doctor on different Claimant's cases read identically or similarly.
- Post office box used for a clinic/doctor address, instead of street address.
- Medical reports appear to be second- or third-generation photocopies.
- Physician cannot be located at address shown on documentation.
- Doctor's report never identifies claimant by gender of gets gender wrong.
- New or additional medical problems are alleged and attributed to the original injury.
- Specific "soft tissue" injury develops psychiatric overtones.
- Treatment as reported by Claimant is different from doctor's statement in medical report.
- Claimant is examined by several doctors when one doctor could have taken all the information and reached a diagnosis.
- Claimant reports seeing doctor for a very brief period of time; however, reports and billing indicate a lengthy visit.
- Claimant sends in medical reports that appear to be altered.
- Claimant lives far from medical facility, yet receives frequent treatment.
- Surveillance shows Claimant's activities are inconsistent with physical limitations related in medical reports and deposition.
- Medical reports contain inaccurate terminology, spelling errors, variations in physician's signature or are rubber-stamped with the doctor's name.
- Medical facility uses multiple names or changes name often.
- Billings are received for unnecessary or not rendered services.
- Medical facility has consistently billed both WC carrier and auto, health, etc., insurance carrier and has received payments from both.
- Claimant is unable to define medical ailments as listed on claim form.
- Claimant alleges doctor or clinic found through a "hot line."
- Claimant filed for unemployment or disability benefits before visiting attorney or clinic.
- Claimant is overly pushy, demanding a quick settlement, commitment, or decision.
- Claimant is unusually familiar with claims-handling procedures, workers' compensation rules, and proceedings.
"Red flags" do not automatically guarantee guilt, but are simply indicators of potential fraud and surveillance should be considered.
To learn more, you may contact us by telephone (203.264.6802) or via email.
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