Workers’ compensation insurance coverage is designed to support workers recovering from workplace accidents and injuries. It saves employers and employees from extensive medical debt and cushions against lost wages.
However, there are reasons for employers to be wary of employees faking injuries to reap the time off and monetary benefits of the compensation. It’s essential that insurance companies and employers can spot employees faking injuries.
Here’s how to spot and prevent workers comp insurance fraud, or you can visit for further information https://www.employers.com/featured/2022/insurance-fraud-example-case-of-the-disappearing-employee/.
What Is Workers Comp Insurance Fraud
Workers’ compensation insurance fraud is when an employee relays false information to an insurer or employer regarding sustaining a work injury eligible for compensation. The primary motivation for most that do this is due to the appealing benefits such as:
- Lost wages
- Permanent benefits for losing any ability (disability benefit)
- Medical treatment costs
- Vocational rehabilitation
Faking an injury is challenging, so such cases are uncommon. The most typical examples of workers comp insurance fraud are often things like:
- Exaggerating the extent of a work-related injury
- Reporting injuries that occurred outside work
- Taking advantage of older injuries caused by other reasons that hadn’t completely healed
- Malingering and refusing to get requisite and adequate treatment and any follow through.
Signs Of A Worker’s Compensation Fraud
There isn’t a single indicator that shows workers comp insurance fraud. You are looking for multiple indicators or patterns of any of the following events that could suggest something is not adding up.
Malingering And Exaggeration
Malingering is amongst the most common types of workers’ compensation insurance fraud. The primary reason is that most employees do not even recognize that they are malingering.
Malingering is when employees refuse to resume work because they’re already used to receiving workers’ compensation benefits, leaving them without motivation to continue working. Sometimes the malingering is also motivated by a fear of getting injured further when they resume work.
Exaggeration is when an employee exaggerates the extent and severity of their injury to receive more benefits. It may also be a tool to malinger and spend more time out of work while still receiving benefits. If you suspect this, ask a different medical practitioner to use their expertise to gauge the extent of the injury.
The Employee Did Not File A Injury Report As Soon As Possible
Work injuries must be reported to an employer as soon as possible, not just for health but also due to notice requirements as per insurance laws. An employee failing to report immediately raises suspicion.
For instance, an employee reporting that they hurt their shoulder three months ago is harder to prove. Timely reports make collecting evidence on the incident and its relation to work more accessible.
Inconsistency In An Employee’s Story
When an employee lies about an injury, there are often some inconsistent aspects of how the injuries occurred. They may show when they report to the employer versus what they say to the doctor, co-workers, and insurance company.
Always note and write everything an employee reports about an injury for records and comparison purposes. Investigate any irregularity and inconsistency.
Employee Refuses To Get Treated
Refusal to receive treatment, especially when advised to go to specialists and specific doctors, is a glaring reason for suspicion of workers comp insurance fraud. While this may not always mean the injury is fake, it could also mean they are malingering by diminishing efforts to heal and resume work.
One of the workers’ compensation goals is to have employees resume work as soon as possible by taking all measures to promote a quick recovery. Declining recommended treatments without any particular rationale is something employers should look into.
Employee With A History Of Making Workers’ Compensation Claims
While a single employee can experience subsequent work injuries, it raises concerns. Employers should scrutinize a serial victim of work-related injuries harder than first-time reports.
A chain of claims may signal that they are faking injuries because they know how the claiming system works. It could also mean that a previous work injury did not completely heal, and there is no new injury.
Measures To Prevent Fraud
Workers’ comp fraud is a grave crime that can strain and burden business operations, diminish the claims of other workers with legitimate claims, and even result in higher insurance premiums for businesses.
While many businesses have installed surveillance cameras to monitor their employees around the clock, they can only offer so much. Other proactive measures can help prevent this fraud. Here are a few:
- Implement and communicate your business’s no-tolerance policies for fraud.
- Promote safety culture by designing, implementing, and maintaining a safe working environment. Accompany this with a safety plan to help ensure all employees know the policies and standards.
- Create an environment where employees feel comfortable enough to report work injuries as soon as possible before they get worse. Fear of authorities may discourage employees from reporting injuries early enough, waiting to see if the pain disappears. The risk of this fear is that should the injury worsen, the employee has to report it, and their delay affects the ability to prove the relationship between the damage and the work incident they claim caused harm.
- Ensure all your employees know the importance of workplace safety and the mitigation of any potential safety and health risk.
- Conduct a legal background check when boarding; this could reveal candidates with previous fraudulent claims.
- Hold regular meetings for safety training and put up posters reinforcing your policies.
Protect Yourself From Frauds
As an employer, you risk losing a lot by being unprepared and lacking the ability to identify the signs of fraud in an employee’s work injury claim. While employers take up workers’ compensation insurance to protect them and their employees, unfortunately, not all your employees may share this good intention.
You can shield your business by equipping yourself by learning about occupational and workplace safety. Reflect on all the indicators of fraud in worker’s compensation, inform your supervisors and managers, and take proactive measures to prevent fraud. Protect yourself from fraudsters.