CRA eJournal

The Six Warning Signs of a Fake Workers’ Comp Claim

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Only a small percentage of workers’ comp claims are fraudulent but letting them go undetected can cost a lot. A woman in Minnesota was suspected of workers’ comp fraud when she showed no signs of injury even though the police report she submitted to substantiate her claim said she had sustained six broken ribs in a car accident that occurred while driving to the airport for a business trip. The employer’s and employees’ suspicions were confirmed and she was arrested for fraud after it was discovered she had used her computer to research accident reports written by the local sheriff’s department, according to a report in the Mankoto Free Press. For the most part, the woman successfully avoided committing five of the six following warning signs of workers’ comp fraud.
1. Late reported claims. When a claim is reported more than seven days after the event, statistics prove that the likelihood of fraud is much greater. Late reported claims are not only more expensive, they end up in litigation much more often. 
2. Monday morning claims. It’s not known whether this claim was reported on a Monday, but when claims are submitted on Mondays, it’s just common sense to question whether the injury might have been sustained over the weekend.
3. The incident had no witnesses. A police report that attests to an injury is pretty solid in this regard. (Unless of course it’s fake.) Most injuries probably occur where they can be witnessed and if not, it’s appropriate to question whether the circumstances of the injury are plausible.
4. The incident is only vaguely described, incomplete as to details or out of the norm of the type of injury that might be expected. A police report is usually detailed enough for most claims examiners. (Unless it’s fake.) Broken ribs are consistent with certain types of vehicle accidents. But what about injuries sustained on the job at your plant or premises? Does the injury seem to fit what could happen to someone performing their normal job duties? 
5. The claimant refuses diagnostic procedures. In addition to faking the police report, the woman apparently alleged having hospital records of her injury. In any case, however, even if not fake, these would not have necessarily provoked suspicion of her claim. Quite often fraudulent claimants just want to get into the system, to get treatment, not demonstrate hard evidence of an injury. They will prefer a chiropractor over an x-ray or an MRI. Fraudsters know that soft tissue injuries can be difficult to evaluate.
In terms of the first five criteria, the Minnesota fraudster had concealed her deception pretty well. But on number six she tripped up. 
6. What are other employees saying about this claim? In this case, no one believed a person could sustain six broken ribs and return to work after only a few days rest at home and show no evidence of the injuries. The tip-off caused the employer to investigate. It was found there were no police or hospital records of the accident in spite of the documentation the claimant used to support her claim. 
Although one in ten employers may worry an employee faked an injury, only about 1-2 percent of claims are fraudulent. Most injured employees are conscientious and concerned about the impact of their injury on the business. Follow up when they are injured and let them know that you value them. And only with the best evidence, ever suspect them of workers comp fraud. 
If you have questions about workers comp fraud, contact the Insurance professionals of EPIC’s CRA ProRental™ Insurance Program. Call us at: 800.234.6363.


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