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What You Need to Know About Investigating Workers Compensation Cases

  • April 30, 2018
  • by Stephanie Irvine
  • Articles

For Private Investigators, investigating workers compensation cases requires ingenuity and time. When a worker is injured on the job, they may be entitled to benefits, including but not limited to, medical bill payment, compensation for time off, and/or other financial benefits. There are two types of workers compensation fraud cases: those in which the employee commits fraud and those in which it is the employer who commits fraud.

Employee Fraud

When a worker knowingly files a false claim in order to obtain benefits, that is fraud. While it seems like this would be a criminal case for the police to investigate, it typically is up to the healthcare companies to investigate and determine whether or not the filing was fraudulent.

Employer Fraud

Employers can also be held liable for fraud in workers compensation cases. While most people first think of an employee faking an injury, employers can also be guilty of committing fraud by denying valid claims, not making disability payments on time, refusing to provide insurance, or by making examples of employees who have submitted claims.

Other examples of employer workers compensation fraud can include misclassification of workers to evade providing benefits. Those cases typically include hiring an employee but improperly claiming that he or she is an independent contractor who is not eligible for workers compensation benefits. Most states have laws on the books that clarify the requirements of what specifically constitutes an employee.

How to Investigate Workers Compensation Cases

When investigating a worker’s compensation case, the investigator is required to do a lot of detective work to first find clues to determine whether or not it is a potentially viable fraud case or whether or not it is a legitimate claim. There are a number of questions that the investigator must ask to determine if the employee has filed a legitimate claim and or if not the employer is responding appropriately. There are several methods that can be used to investigate workers compensation cases, the most common include surveillance, public records and background checks.

Accident Reconstruction

If the claim involves a vehicle or motor collision, private investigators may be asked to recreate the accident to determine the plausibility of its occurrence. The investigator will reconstruct the accident, analyze external and internal factors, and determine who is at fault. This is the very first step in an investigation for a workers compensation case because it is critical to know what the evidence will show, especially if the case is argued in court.

While not an explicit component of accident reconstruction, private investigators will often interview witnesses to the accident and/or employees to get a true understanding of who is at fault. Additionally, these interviews can help serve as corroborating witnesses in court, whether it is the employer or the employee committing fraud. Understanding the conditions of a workplace can help paint the picture of what really happened.

Surveillance

Surveillance is an important component of a private investigator’s job. While it is time-consuming, the evidence procured through surveillance can be helpful in proving certain allegations after a work accident occurs. When it comes to worker’s compensation, surveillance can prove or disprove the legitimacy of an injury and is most commonly used to investigate employee workers compensation fraud.

During surveillance, a private investigator can take time and date-stamped photographs of a worker in seemingly normal health. If a worker is injured on the job and claims he or she is unable to perform work due to their injury, surveillance can show whether or not he or she is truly injured through photographic evidence procured during a surveillance operation. For example, if a worker claims a back injury that prevents them from lifting 50 pounds, but then is photographed lifting 100-pound weights at the gym, that could be used as evidence against him or her in court. While this is a hypothetical situation, it demonstrates the importance of surveillance.

Similarly, surveillance can be used to investigate employers and their treatment of employees. However, employer investigations often utilize other methods like those below.

Public Records Investigations & Background Checks

The adage that “old habits die hard” is oftentimes true. If an employee pursues worker’s compensation cases against multiple employers, they create a history of attempting to game the system. This history may be proof that the individual has patterned behavior — especially in situations where a worker made multiple attempts to win workers compensation cases in court but failed as the subsequent cases proved that the individual’s claims were unwarranted.

Additionally, public records may turn up additional addresses where the claimant may be staying. It is not unlikely that an employee who has filed a fraudulent workers compensation case would be “hiding out” at another location until the case settles. Faking an injury is a lot to take on, and it may be a lot of pressure to “perform” the injury. Hiding out in a location the claimant feels safe is one way to avoid having to put on the act — and it is also a great location to catch the claimant in a lie.

From the employer fraud standpoint, a company that has a record number of claims against them may help to prove a pattern of negligent employer behavior. That type of patterned behavior could weaken the credibility of the person or company in the wrong.

Beyond public records investigations, background checks will show any criminal history of the claimant may have had or for an employer: their record of complaints and company filings. If a company is owned by an individual but the individual continuously operates in a cycle of operating the same business under new names and corporations that have been found guilty of committing workers compensation fraud, they may be at the root of the problem. While this in and of itself will not be proof, it can add to the character of the individual or the company and how trustworthy they are.

Gaining Experience

Workers compensation cases are often a lucrative and steady source of investigations for private investigators, especially as they build a reputation for providing solid evidence. What are your favorite tips for conducting a workers compensation investigation? Let us know in the comments.


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