WORKERS  COMPENSATION  FRAUD

Fraudulent workers compensation claims can cost an employer dearly, through higher rates to a workers compensation account, by draining the funds of self-insured companies, or via the law suits claiming negligence which often accompany them. Even though workers compensation fraud is a felony, false claims still are filed by the thousands. Why would someone commit such a fraud if the consequences could be so dire?

First of all, the chance of getting caught in workers compensation fraud is usually very slim, especially compared weighed against the benefit of money without work! States have only a handful of investigators who are so backed-up that the majority of claims, even the suspicious ones, are never investigated. This is why so many employers rely on the efforts of private investigative firms such as ours. Usually, an employee simply files the claim  with the state and throughout the process the employee is given benefit of the doubt and is paid. Even when employers contest a claim, the employee is favored and has the odds far in their favor. RSA knows this process and knows when and where it can be checked to stop fraudulent claims before they cost you.


Secondly, many fraudulent claims involve injuries that are almost impossible to disprove. Injuries to the back, neck, or knees, or nerve damage, are commonly used deceptions because even the best doctors and most sophisticated equipment can not say with certainty whether a person is in pain due to injuries suffered in these areas, and those committing fraud know this. Regardless of  today's medical technology, a person's complaint alone can still be the basis of a costly claim. Therefore, often the only way to determine whether someone has overstated any injuries is to actually witness that person in their daily activities. If someone claims to be unable to walk, yet they are observed playing basketball, then obviously that claim needs to be revaluated! Acquiring and documenting such unquestionable proof is the expertise of RSA.

The above factors make it very difficult  for employers to successfully challenge fraudulent claims without outside investigative help. Further frustrations to such efforts include:

     *  The incident of supposed injury may not have been properly investigated by the employer.

     *  Witnesses may have not been identified and their statements taken.

     *  Sympathy for the allegedly injured person may replace proper thoroughness in fact-finding.

     *  Many doctors and clinics are willing to substantiate and perpetuate unfounded injury claims.

     *  Employers fear lawsuits if they delve too far into the facts of an injury.

Often devious employees totally fabricate a scenario just to file a claim and collect benefits. Other times, real but relatively minor injuries do occur, but then are exaggerated, often in response to friends who encourage the employee to "milk" the claim for everything it is worth. However, it must be remembered that not all workers compensation claims are fraudulent. Many claims are legitimate and the injured worker is justly entitled to benefits. Employees who are honestly injured should be protected to the extent of their actual injuries--nothing less, but nothing more.


Here are some real scenarios our firm has encountered which serve to illustrate typical deceptions and the importance of our investigations in stopping them:

CLAIM:  Worker broke his leg while walking up a set of stairs at a client's location

FACT:    He did break his leg, but not while working for the employer he filed the claim against. Our firm learned that he sustained the injury while moonlighting for a competitor, and then filed the claim against his full-time employer because he was not covered under the other part-time employer who was paying him under the table. Employee was fired and termination was upheld.


CLAIM:  Employee breathed toxic vapors while working in a dangerous environment.  Supposedly he was totally incapacitated due to nerve damage, rendered unable to perform the simplest functions of daily life.

FACT:    Hundreds of other workers who worked in same environment had no injuries or complaints. Worker was observed by our investigators riding untamed horses while operating a horse-riding business on the side. Employee was fired and this action was upheld in appeal.


CLAIM:  Worker complained of severe back injuries incurred while lifting at an industrial location. Stated he was unable to perform any work duties.

FACT:  Our investigators discovered that the subject operated a small business on the side selling chain saws, and that he had even entered a Paul Bunyan Contest in which he vied to cut a log into slices within the shortest amount of time. He almost won that contest, but lost his job and his fraudulent claim.


Investigations to stop workers compensation fraud more than pay for themselves as they keep your rates low and keep your company out of court. Once you take action against fraud, the message will resonate to all employees: crime does not pay...at least not with this company.

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