My OperaL&W Investigations, L & W Investigations
Monday, August 19, 2013 6:43:51 AM
L&W Investigations, L & W Investigations
There's a general misperception that people who file worker's compensation claims aren't "really hurt." Truth be told, about 80 percent of all worker's comp claims filed are legitimate, from people who genuinely are injured and entitled to their worker's compensation claim.
Does that mean companies should rubber-stamp every worker's comp claim? No, but it's important to realize that everybody who does file a claim is not trying to take advantage of the system.
As an insurance professional, there are some red flags you should be aware of so that you can detect a claim that might not be on the up and up. Some of the things you should be on the lookout for include:
4 Multiple claims - has the claimant filed more than one worker's comp claim in the past or a number of claims within a short period of time (e.g. three in one to two years)?
4 Longer absences than anticipated for minor injuries; an unwillingness to come back to work on partial duty or other jobs within the company.
4 The claimant was experiencing financial difficulties and/or domestic problems prior to submission of claim.
4 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.
4 Lawyer's letter of representation or a letter from medical clinic as the first notice of a claim.
4 The claimant reports an alleged injury immediately following disciplinary action, notice of probation, demotion or being passed over for promotion.
4 There are no witnesses to the accident, or witnesses to the accident conflict with the claimant's version or with one another.
4 The accident or type of injury is unusual for the claimant's line of work.
4 The claimant frequently changes physician or does so after being released to return to work.
Substantiating these red flags can often require help from an investigator. The critical element of working with an investigator is for you or your clients to provide them with the most up-to-date information on the claimant as possible. In most cases, the quality and depth of that information will determine the success or failure of the investigation.
Why? Because 20 percent of all workers’ comp investigations will require video surveillance of the claimant; an operation that generally occurs over two to three days in eight-hour shifts. So if the investigator does not have the necessary information and intelligence-name, photo, physical description, current address, injury and its limitations-the investigation is doomed to fail from the start.
Once the investigator can positively identify the claimant, then it's a matter of continuing surveillance and documenting behavior and actions. If he or she is going to a second job during the day or hitting the gym to train for a triathlon, the video surveillance and subsequent report will tell the story and you'll know that the claim is fraudulent.
Again, that's not to say you should suspect every claim that comes across your desk as somebody trying to get away with something. Quite the contrary, if somebody's injured on the job; it's the job of the insurance company to pay that claim.
As an insurance professional, your best defense against less than credible worker's comp claims is to keep an eye out for the aforementioned red flags. If you're also an employer, you'll also want to watch out for the red flags and, most importantly, keep current records on your employees. Make it a point to have employees update their information annually. Keep photos on file of your employees, whether it's their ID badge photo or just get in the habit of taking a photo of all new employees. If you're a larger company, you may want to consider a toll-free fraud hotline for employees to report abuse anonymously.
Bogus worker's comp claims cost businesses in the billions each year, both in lost man-hours, medical payments and increased premiums. By simply increasing your awareness and making a few procedural changes (e.g. keeping current employee information) you can greatly reduce the impact worker's comp claims have on your client's bottom line and yours.
There's a general misperception that people who file worker's compensation claims aren't "really hurt." Truth be told, about 80 percent of all worker's comp claims filed are legitimate, from people who genuinely are injured and entitled to their worker's compensation claim.
Does that mean companies should rubber-stamp every worker's comp claim? No, but it's important to realize that everybody who does file a claim is not trying to take advantage of the system.
As an insurance professional, there are some red flags you should be aware of so that you can detect a claim that might not be on the up and up. Some of the things you should be on the lookout for include:
4 Multiple claims - has the claimant filed more than one worker's comp claim in the past or a number of claims within a short period of time (e.g. three in one to two years)?
4 Longer absences than anticipated for minor injuries; an unwillingness to come back to work on partial duty or other jobs within the company.
4 The claimant was experiencing financial difficulties and/or domestic problems prior to submission of claim.
4 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.
4 Lawyer's letter of representation or a letter from medical clinic as the first notice of a claim.
4 The claimant reports an alleged injury immediately following disciplinary action, notice of probation, demotion or being passed over for promotion.
4 There are no witnesses to the accident, or witnesses to the accident conflict with the claimant's version or with one another.
4 The accident or type of injury is unusual for the claimant's line of work.
4 The claimant frequently changes physician or does so after being released to return to work.
Substantiating these red flags can often require help from an investigator. The critical element of working with an investigator is for you or your clients to provide them with the most up-to-date information on the claimant as possible. In most cases, the quality and depth of that information will determine the success or failure of the investigation.
Why? Because 20 percent of all workers’ comp investigations will require video surveillance of the claimant; an operation that generally occurs over two to three days in eight-hour shifts. So if the investigator does not have the necessary information and intelligence-name, photo, physical description, current address, injury and its limitations-the investigation is doomed to fail from the start.
Once the investigator can positively identify the claimant, then it's a matter of continuing surveillance and documenting behavior and actions. If he or she is going to a second job during the day or hitting the gym to train for a triathlon, the video surveillance and subsequent report will tell the story and you'll know that the claim is fraudulent.
Again, that's not to say you should suspect every claim that comes across your desk as somebody trying to get away with something. Quite the contrary, if somebody's injured on the job; it's the job of the insurance company to pay that claim.
As an insurance professional, your best defense against less than credible worker's comp claims is to keep an eye out for the aforementioned red flags. If you're also an employer, you'll also want to watch out for the red flags and, most importantly, keep current records on your employees. Make it a point to have employees update their information annually. Keep photos on file of your employees, whether it's their ID badge photo or just get in the habit of taking a photo of all new employees. If you're a larger company, you may want to consider a toll-free fraud hotline for employees to report abuse anonymously.
Bogus worker's comp claims cost businesses in the billions each year, both in lost man-hours, medical payments and increased premiums. By simply increasing your awareness and making a few procedural changes (e.g. keeping current employee information) you can greatly reduce the impact worker's comp claims have on your client's bottom line and yours.
