Red Flags: Top 10 Questions to Ask Yourself
 May. 25, 2011

An employee getting injured at work is very difficult for all parties involved. What do you do if you start to wonder about the injury? Here are ten questions you can ask yourself about a claim. These "red flags" are not an indication (even if there are several of them) that there is a problem with the claim. It could mean that the claim should have more attention. Please remember, insurance fraud can never be assumed. It must be verified by a complete investigation and a court of law.

    1. Is the employee always out when you call them at home? You contact your employee to check and see how they are doing, and you always get voice mail or someone that tells you the person is out. Does the family member you talk to have no knowledge of the employee’s injury or that they are not currently at your workplace? If you are repeatedly unable to reach your employee when they should be at home recuperating, inform your carrier.

    2. Do they follow doctor’s orders in order to recover quickly? Does the employee miss appointments on a regular basis? Does the applicant refuse further testing that would confirm the injury? Someone interested in recovering will make the appointments that will help them return to work.

    3. Did anyone see the accident? A lack of witness, especially if you have a busy workplace, is highly unlikely. If you do have a witness statement, is it consistent with what the employee reports?

    4. Was an incorrect home address or phone number provided to you? Does the employee hand deliver all paperwork and avoid using U.S. mail? Does their address change frequently? If mail is being returned or the home and contact phone numbers are invalid, inform your carrier.

    5. When did the accident happen? Was it a claim that "was not reported" but occurred during the last part of a shift on a Friday? Was it first thing on a Monday morning after the employee was off for the weekend? If the accident happens late in the last shift of the week or early in the first shift after being off work, inform your carrier as the accident needs extra attention.

    6. Are you talking about company and department lay-offs or possible disciplinary actions that involve the employee? If an employee is aware of the possible action or loss of work, a claim for injury may be made to improve the employee financially or to delay a termination.

    7. Where did the accident happen? Was a manufacturing employee injured in the shipping area? Was the employee injured in a remote area that they are normally not assigned? Is the injury inconsistent with the type of work the employee is assigned?

    8. Did the employee retain an attorney immediately after the injury? An employee, who is receiving immediate medical attention and is in contact with you and your insurance carrier, should not feel the need to hire an attorney at the very start of the claim.

    9. Does the employee know more about the process than your risk manager or human resource department? An experienced repeat claimant will use insurance terms that they would not normally be familiar with and use in conversation.

    10. Do the accident statement and details match a current or previous claim you have? This can indicate a training or problem area for injuries. It can also indicate that two or more employees are filing false claims and they are discussing what to say to you and to the carrier for increased time off, and increased benefits.

It is important to remember that the presence of a red flag does not mean that the claim is fraudulent. It means that the accident needs to be investigated completely. All employers should be aware of potential fraud and discuss any concerns with their Workers’ Compensation carrier for further investigation. For more information, please contact your insurance carrier or visit the California Department of Insurance website at www.insurance.ca.gov. Insurance fraud costs employers, insurance carriers, and consumers over five billion dollars annually. (California Department of Insurance, 2011)

Thank you to CompWest, CMTA’s Group Workers’ Compensation partner, for this contribution to CompCheck. If you have questions about this article please contact CompWest at 888-266-7937.

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