How to Identify a Fraudulent Workers Comp Claim

How to Identify a Fraudulent Workers Comp Claim

After filing a workers comp insurance claim for a shoulder injury he suffered working for the federal postal service, the recipient of the benefits was spotted working as a massage therapist. This lead to felony charges related to the fraud.

An ‘injured’ entertainer was seen dancing in a popular television commercial while he collected a surplus of fifty thousand dollars in workers compensation payments related to a previous disability claim.

After submitting a workers comp claim about an injury incurred while on the police force and collecting more than thirty thousand dollars in benefits for it, the former officer was found to be working for a musical band – something he would not have been able to physically do if his claim to injury was genuinely true.

If you really delve deeply into it, you will find more and more bizarre stories about workers comp fraud. Thankfully, the ratio of these is quite slim in contrast to the valid ones. For the small business owner and the large commercial enterprises, it is vital to be in the know about detecting abuse of the system.

5 Ways to Understanding Workers Comp Fraud

1. Something may not be right when a worker files a workers compensation claim for an injury that supposedly occurred seven or more days before that.

Here’s what to do if this happens. Speak to the injured worker, as well as fellow employees to gather information about the incident and draw your theory of a conclusion.

2. A workers compensation claim that was filed immediately after the weekend may indicate the injury was incurred away from the work site.

This is what you should do if this happens. Investigate if the worker has interests in hobbies or sport activities that may have triggered the injury. Conduct interviews with the other employees to discern if they have any knowledge about whether the claimant partook in this type of weekend activity. Keep your eyes open for verbal or body language that demonstrates the worker is lying.

3. No witnesses of the injury could mean that the claimant is not genuine.

Here is what you can do in this case. Make the appropriate inquiries with others if anyone saw the claimant immediately following the said injury.

4. What if the claimant wants to be treated without getting an x-ray, MRI or other injury defining testing?

This is what you can do in this situation. Ask the claimant why he or she is not interested in documented diagnosis. Demand that he or she undergoes this required diagnostic testing.

5. Any claimant that does not offer a clear picture of what occurred when he or she was injured is subject to suspect.

Here is what you should do in this scenario. Take all details of the report while using your knowledge of the usual state of affairs at your business site. Look out for any inconsistencies in his account.

If you findings in relation to the above points do not justify the claimant, do not hesitate to bring your thoughts to the claims department of your insurance company.


Workers Comp

Workers’ compensation, also known as workers’ comp, is a form of insurance that provides medical benefits and wage replacement to employees who suffer work-related injuries or illnesses. It is designed to protect both employees and employers by providing financial support and ensuring that injured workers receive proper medical care.

Here are some key points to understand about workers’ compensation:

  1. Coverage: Workers’ compensation laws vary by country and region, but in general, most employers are required to carry workers’ compensation insurance. The coverage typically applies to all employees, including full-time, part-time, and seasonal workers.
  2. Benefits: Workers’ compensation benefits aim to cover medical expenses related to the work-related injury or illness. This includes doctor visits, hospitalization, medication, physical therapy, and rehabilitation. In addition, workers may receive wage replacement, typically a portion of their regular wages, during the period they are unable to work due to their injury or illness.
  3. No-Fault System: Workers’ compensation operates on a no-fault basis, meaning that employees are entitled to benefits regardless of who caused the injury or illness. Even if the employee’s own actions contributed to the accident, they are still generally eligible for benefits, with some exceptions for cases involving intoxication or intentional self-harm.
  4. Exclusions: While workers’ compensation covers most work-related injuries and illnesses, there are some exceptions. Injuries resulting from employee misconduct, such as fighting or willful negligence, may not be covered. Similarly, self-inflicted injuries and injuries occurring while the employee is not on the job are typically not eligible for benefits.
  5. Filing a Claim: To receive workers’ compensation benefits, an employee must report the injury or illness to their employer within a specified timeframe. The employer then assists in filing the necessary paperwork with the workers’ compensation insurance provider. The claim is evaluated by the insurer, which determines the eligibility for benefits based on the circumstances of the case.
  6. Legal Support: In cases where a workers’ compensation claim is denied or disputed, employees have the right to seek legal representation to appeal the decision or to navigate the legal process. Workers’ compensation laws can be complex, and having legal assistance can ensure that employees receive the benefits they are entitled to.

It’s important to note that workers’ compensation laws can differ significantly between countries, states, and provinces. If you have specific questions or need detailed information about workers’ compensation in a particular jurisdiction, it’s advisable to consult with a legal professional or the appropriate government agency responsible for overseeing workers’ compensation.

Prepare and write by:

Author: Mohammed A Bazzoun

If you have any more specific questions, feel free to ask in comments.


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