The following is my top 40 list of fraud or abuse Red Flag signals for workers claiming injury on the job.  Remember that even if the claim has all of these red flags, there is not necessarily FRAUD being committed nor do you have grounds to deny or dispute the claim. However, if you discover some of these red flags, you should investigate further and bring the results to the attention of your Insurance Claims Adjuster. 

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Watch out for:

1. Late reporting – If an individual is really injured on the job, it is unlikely the employee will wait days or weeks to report the injury.

2. The employee changes the description of the accident when inconsistencies are pointed out.

3. The nature of the injury is not consistent with the normal work done by the employee.

4. The date, time or location of the accident is unknown or forgotten.

5. The accident occurs in an area where the injured employee or claimant would not normally be.

6. Fellow workers hear rumors circulating that the accident was not legitimate.

7. The employee gives completely different versions of the accident to the employer, the adjuster and the doctor.

8. The employee leaves out pertinent information.

9. There are no witnesses to the accident, and the employee normally works around other people.

10. There are witnesses, but their version of the accident differs from the employee’s.

11. The nature of the injury is unusual for the employee’s line of work.

12. The employee is disgruntled about some aspect of his job.

13. The employee is on the list to be laid off.

14. The employee is on “warning or counseling” status and is about to be terminated.

15. The employee has had numerous prior injuries.

16. The “accident” occurs immediately before a strike, plant closing or the end of seasonal employment.

17. The accident occurs near the end of probationary period.

18. The claimant is a seasonal worker.

19. The employee has an early Monday morning accident before the supervisor or other employees see him on the job (meaning the accident might have occurred off the job over     the weekend).

20. The claimant uses the address of friends or family members and has no definite address or uses a Post Office box as an address.

21. The employee’s spouse is not working and is drawing workers’ comp indemnity benefits,     Social Security disability payments, welfare or unemployment insurance, and the employee appears to want the same lifestyle.

22. The employee inquires about a settlement early in the claim process.

23. The employee was having financial problems.

24. The employee took excessive time off just before the injury.

25. The employee is in the middle of a divorce or other family disturbance.

26. The employee applies for Social Security benefits before the injury occurs.

27. The Income from workers’ comp, disability or other sources exceeds the employee's prior after-tax income.

28. The employee protests about returning to work and never seems to improve.

29. All the injuries are subjective – pain without trauma, soft-tissue, emotional.

30. The employee has excessive treatment for soft-tissue injuries.

31. The nature of the medical treatment changes from one body part to another after the employee has been treating for a while.

32. The employee misses medical appointments.

33. The employee fails to show up for an independent medical examination.

34. There are whiteouts, corrections or erasures on medical forms submitted by the employee.

35. The employee has a history of multiple workers’ comp claims or reporting subjective  complaints of pain without medical treatment.

36. The length of recovery seems excessive for the nature of the injury.

37. The employee who has been off work for a long time has calluses on his hands or grime    under his fingernails.

38. The employee says he is unable to work because of an injury but is seen painting the house, mowing the lawn, carrying heavy objects, etc.

39. The employee has a high-risk hobby or does other activities involving considerable physical exertion.

40. The employee is a part of a group of employees using the same doctor and the same     attorney for their workers’ comp injuries.​

 

Disclaimer: The information in this article does not constitute legal advice, nor is it intended to create an attorney-client relationship. Every situation is unique, and I encourage you to seek legal advice from a licensed attorney for your particular situation.

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