Practice Pointers: Tips on Identifying Fraudulent Claims

Workers’ compensation fraud is a topic of considerable discussion. The workers’ compensation system in California is a no-fault system. This means that an employee is not required to prove fault or negligence to receive workers’ compensation benefits. Unfortunately, some employees take advantage of this system by filing fraudulent claims that involve fabricated or exaggerated injuries. The resulting consequence is that insurance companies are left holding the bill, and the costs are eventually borne by the general public.

Insurance professionals, employers, claim representatives, and defense attorneys can employ certain investigative tactics to identify and combat fraud. Below are some useful tips to help identify fraudulent claims.

  • Consider whether the incident was reported on a Monday, or after the claimant has returned from vacation.
  • Consider whether there were any delays in reporting the claim.
  • Inquire whether there have been any changes at the workplace, such as a notice of lay-off, termination, or rumors of a strike.
  • Investigate whether the claimant has been experiencing any performance or disciplinary issues at work.
  • Determine whether the claimant’s description of the alleged injury is consistent with the statements to medical providers.
  • Find out whether the claimant has a history of filing worker’s compensation claims.
  • Consider whether the claimant has a child support lien, tax lien, or any other significant financial obligations.
  • Inquire whether the claimant engages in any hobbies outside of work.
  • Consider whether the claimant has any personal issues or domestic problems.
  • Obtain a detailed statement early in the investigation from the claimant, employer, and any witnesses.
  • Review the Internet and social media sites to identify any activity that may be inconsistent with what was reported by the claimant. Create a Google alert that will send you an e-mail when the claimant’s name is mentioned on the Internet.
  • If a claim seems suspicious, consider surveillance.

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