Insurance Business of America published a story earlier this month highlighting 10 “red flags” that signal an employee is attempting to scam the workers’ compensation system. The list provides troubling insight into the insurance industry’s treatment of injured workers. Today, Workers’ Compensation attorneys Mike Lammers and Ben Heimerl give their take on the list.

Here are the 10 “red flags” according to Insurance Business of America. Mike’s response to each item is below the italicized description.

1. 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.

Wow. This really sets the tone for the article: nonsensical and cynical. The article doesn’t begin to explain why a Monday morning injury is suspicious – probably because they can’t. As far as the implication that a Friday afternoon injury not reported until Monday is suspicious or unusual, that too is just plain cynical. There are all kinds of common sense reasons an injury isn’t reported immediately.

2. Employment change – The reported accident occurs immediately before or after a strike, job termination, layoff, end of a big project, or at the conclusion of seasonal work.

Before OR after ANY of those events? Could the author be any less specific? In today’s economy, people have employment changes all the time. If employers and insurers are going to be suspicious of every person before and after a job change, there won’t be anyone left to trust!

3. 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.

This is a nice piece of circular logic:  How do you know if there is a suspicious claim? If they go to a suspicious doctor. How do you know if it is a suspicious doctor? If they handle suspicious claims, of course. Rinse and repeat.

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

I don’t know why the focus here is on witnesses. People get legitimately hurt at work without witnesses often. Think about your own job. Is someone watching you all the time? Just because no one witnesses a work injury doesn’t mean the injured person is committing fraud. The second part of this “red flag” would make more sense: if the employee’s account of what happened just doesn’t sound right, it’s probably a good reason for a second look.

5. Conflicting descriptions – The employee’s description of the accident conflicts with the medical history or First Report of Injury.

This might seem like a good way to sniff out fraud, but I think it is a red herring. Medical histories are complicated. Medical records are tough to read. Unless the employer happens to be a hospital, it is probably best to leave the diagnosis and prognosis to the doctors.

6. History of claims – The claimant has a history of a number of suspicious or litigated claims.

Again, self-serving and circular. If the employer uses this list to determine a claim is suspicious, then almost EVERY claim would be suspicious. At the end of the day, what they are saying here is: If the employee has had a previous work injury, then they are suspicious.

7. Treatment is refused – The claimant refuses a diagnostic procedure to confirm the nature or extent of an injury.

This is pure fantasy. Employees don’t refuse diagnostic procedures. They just don’t. The only people who refuse diagnostic procedures in a work comp setting are insurance companies who don’t want to pay for them.

8. Late reporting – The employee delays reporting the claim without a reasonable explanation.

The key word here is “reasonable”. Late notice by itself doesn’t make an injury suspicious. As the link we provided above explains, there are a lot of good reasons people don’t report their work injury right away – they’re afraid of losing their job, they don’t realize that the injury falls under work comp, they think the injury might resolve on its own, etc.

9. Claimant is hard to reach – The allegedly disabled claimant is hard to reach at home.

This one is too dumb to comment on.

10. History of Changes – The claimant has a history of frequently changing physicians, changing addresses and numerous past employment changes. 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, these are simply indicators. Many perfectly legitimate claims are filed on Mondays—and some accidents have no witnesses.

This convenient catch-all really encourages employer paranoia, and should also trouble any employee who has ever changed doctors, jobs or addresses. Two out of three and you make their list. At least the author acknowledges that these are only “indicators” and seems to recognize that there is such a thing as a legitimate claim.

Ben Heimerl Chimes In

As Mike points out, each “Red Flag” raised by this article could have several perfectly reasonable explanations. Unfortunately, insurance companies are training their employees to focus in on one, negative, remote possibility.

Fraud is a serious accusation and should be taken as such. In my experience it is extremely rare. In fact, we’ve never had a client accused of workers compensation fraud. Think about it – in order for someone to commit workers’ compensation insurance fraud they would have to convince their doctor, their employer, their case manager, perhaps a physical therapist, an attorney, and eventually even a judge that they are injured and that the injury arose at work. Or, alternatively, all those people would have to be in on the con. Then, while they are waiting for the big pay day (a whopping 66 percent of what they would have made had they kept working), they will have to fight the insurance company, go months without a paycheck, incur massive debt due to medical bills, ruin their credit score, and possibly get evicted or divorced from the stress of no income. If such an individual was willing to endure all of that, he or she is probably smart enough to have already figured out not to report his injury first thing Monday morning.

All this article is doing is making it more likely that honest injured workers won’t get the benefits they deserve.

Related source: Insurance Business of America

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