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Workers' Compensation Insurance

June 2nd, 2011

10 Indicators of Workers Comp Fraud

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Martin Summers

Insurance Agent

Workers compensation insurance fraud is a big deal and is estimated to cost insurance carriers and business owners over 6 billion dollars each year. Experience shows that when two or more of these factors are present in a workers’ compensation claim, there is a chance the claim may be fraudulent. Remember though, that these are simply indicators. Many perfectly legitimate claims are filed on Mondays – and some accidents have no witnesses.

  1. Changes: The claimant has a history of frequently changing physicians, changing addresses and numerous past employment changes.

  2. Claimant is Hard to Reach: The allegedly disabled claimant is hard to reach at home.

  3. Conflicting Descriptions: The employee’s description of the accident conflicts with the medical history or First Report of Injury.

  4. Employment Change: The reported accident occurred immediately before or after a strike, job termination, layoff, end of a big project, or at the conclusion of seasonal work.

  5. History of Claims: The claimant has a history of a number of suspicious or litigated claims.

  6. Late Reporting: The employee delays reporting the claim without a reasonable explanation.

  7. Monday Morning Reports: The alleged injury occurs first thing on Monday morning, or the injury occurs late on Friday afternoon but is not reported until Monday.

  8. No Witnesses: There are no witnesses to the accident and the employee’s own description does not logically support the cause of injury.

  9. Suspicious Providers: An employee’s medical providers or legal consultants have a history of handling suspicious claims, or the same doctors and lawyers are used by groups of claimants.

  10. Treatment is Refused: The claimant refuses a diagnostic procedure to confirm the nature or extent of an injury.

If you question the validity of a workers comp claim, please contact the claim adjuster at your insurance company immediately. You can also read more information in this article on how to report workers comp insurance fraud in Florida.

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