Diligent Investigation of Workers' Compensation Claims Prevents Fraud


Every year, workers' compensation carriers pay out millions of dollars in benefits to employees that have been injured on the job for medical treatment, lost income or permanent disability. While the majority of the employee claims are legitimate, there are unfortunately a number of fraudulent claims unknown by the carrier. With proper investigation, however, carriers can reduce the possibility of compensating a fraudulent claim.

Proper investigation of claims requires the cooperation of both the employer and employee. Once a claim is reported by an employee, the employer should immediately prepare the First Injury Report and also notify its workers' compensation carrier. If the claim is questionable, photos of the scene should be taken. The employee should be asked to confirm details of the accident. Any contrary facts from other employees should be documented at once. The employer should have an incident form completed by the supervisor and the employee with the employee's signature.

Upon receipt of a claim, a carrier may find that further investigation is necessary before deeming an accident compensable including an ISO for prior or pending claims and also a search with the Division of WC for claims. The carrier will look to the employer for any information regarding the accident and may request the employee's personnel file. Often carriers will hire an investigation company to look into the circumstances of the accident. This may require the investigator to go to the accident site. Moreover, the investigator may request statements from the employer, witnesses to the accident or from the employee.

In order to fully investigate a claim, a carrier may determine that surveillance of an employee is necessary. A good example of when surveillance may be utilized is when an employee has been treated for years with no end in sight. Successful surveillance includes observing an employee working out at the gym lifting weights despite his alleged back injury or an employee running a marathon despite an alleged knee injury.

A case recently described in the Paterson Times demonstrated the use of surveillance that prevented a fraudulent claim from continuing. The article discussed a fire captain who was terminated after being caught on surveillance shoveling snow, bending and lifting while on leave and collecting workers' compensation benefits. The surveillance was arranged by the Paterson's risk management office. If the risk management office had not taken the time to review the claim, the city could have continued to pay the claim for years.

Taking the time to fully investigate a claim can make a difference to an employer and carrier which could possibly end expensive, continued payment of workers' compensation benefits of fraudulent claims.

For more information please contact Cheryl A. Binosa at cbinosa@wglaw.comor 973.854.1062.

Disclaimer: The contents of this post are for informational purposes only, are not legal advice and do not create an attorney-client relationship.

back to top