Workers’ compensation is an insurance program meant to support those who are hurt on the job so they can recover and return to work. In most cases, it works as intended, and everyone benefits. However, employers are wary that some employees may fake injuries to reap both monetary benefits and paid time off. This is a type of insurance fraud called workers’ compensation fraud.

Understanding what workers’ compensation fraud is and how to spot it can be useful if you need to claim these benefits. Knowing what might make your claim look suspicious can prepare you to avoid those actions and stand up to potential fraud accusations from your employer. Let’s investigate what this term means from the viewpoint of a worker’s compensation attorney.

What Is Workers’ Compensation Fraud?

Workers’ compensation is designed to financially support injured workers as they recover from a workplace injury. It helps employees get back to work quickly without incurring significant amounts of medical debt. When the system works properly, it is a win for everyone, from employers to workers.

Workers’ compensation insurance fraud mainly refers to any time a worker makes a false statement to an employer or insurer so they can receive benefits without sustaining an eligible job injury. Some people do this because workers’ compensation, as well as disability benefits, are very appealing.

Benefits from Pennsylvania workers’ comp insurance include:

• Coverage of medical treatment
• Lost wage payments (based on your average weekly wage)
• Long-term benefit payments if you are permanently totally disabled
• Vocational rehabilitation

Although stopping workers’ comp fraud is a high priority for employers and their insurance companies, fraudulent claims do not actually occur very often. In the vast majority of cases, an injured employee is just as hurt as they claim. However, an insurance company may still accuse a worker of workers comp fraud and conduct an investigation, even when it is not necessary.

What Are Some Examples of Workers’ Comp Fraud?

It is difficult to fake an injury, so those types of workers’ compensation fraud cases are not common. Instead, workers’ comp fraud cases will focus on things like:

• Injuries that actually occurred off of the job, but the worker claims are work-related
• Damages that are not as bad as a worker is claiming
• Older injuries that were caused by something else that did not heal completely or very well
• Refusing to get adequate treatment or follow through with recommended care, known as malingering

Insurance companies have a financial responsibility to be on the lookout for these common types of work comp fraud. Unfortunately, those who make false claims abuse the system in a way that ends up hurting everyone. When enough cases of legitimate fraud are discovered, those who are suffering real injuries may be at risk of suspicion, leading to delayed or denied benefits.

Signs of Workers’ Compensation Fraud

If you have a legitimate claim (and chances are that you do), you should not have to worry about being accused of workers’ compensation fraud. However, there are a few things you can do to decrease the likelihood that an insurance company will accuse you of gaming the system.

Malingering is one of the most common forms of workers’ compensation fraud. Unfortunately, it is so common that some workers may not even realize that they are doing it. Malingering occurs when a worker declines to go back to work, even if they have been released to do so. 

They may have gotten used to the workers’ compensation payments and time away from their job. They may simply have no motivation to go back to work. Often, malingering includes a fear that returning to the same environment where you were hurt will end up injuring you further, even if your doctor says that you should go back.

 

1. The Employee Is Refusing Treatment

Getting treatment only when you want or declining to go to specific doctors or specialists could be a sign of workers’ compensation fraud. It does not necessarily signify that your injury is not real, but it could indicate that you are not making a sincere effort to heal and get back to work. Part of the goal of workers’ compensation is to get you back to work quickly, which means healing quickly as well.

Declining to get the recommended treatment, particularly without any rationale, could be a sign of malingering. Failing to attend appointments could also threaten your workers’ compensation benefits. It is very important to participate in all necessary treatments. 

If you feel you have a legitimate reason for not following your doctor’s orders, speak with your worker’s compensation attorney about how this might result in fraud allegations against you. Your lawyer can assess your situation and ensure you are being treated fairly.

 

2. The Employee Didn’t Report the Injury Right Away

You must report a work injury to your employer as soon as possible. The law requires you to do so within 21 days or risk being denied coverage. It is not only a good idea for your health, but there are notice requirements that you must meet to get benefits under Pennsylvania law.

Failing to timely report also increases an employer’s suspicions that you were not injured at work. For example, if a worker says that they injured their shoulder two months ago, it is harder to prove that the injury was from work rather than something else that happened during those two months. It also makes gathering evidence of the incident harder for the employer as well.

 

3. The Employee Has a History of Making Workers’ Comp Claims

The more workers’ compensation claims you have had in the past, the more likely the insurance company will carefully scrutinize your injury today. They do this for a couple of reasons. First, it could be a sign that you are “faking” the injury because you know how the system works and how to use it to your advantage.

Second, it could also mean that you injured yourself at work on a different occasion and that injury never healed properly. To the insurance company, that may mean that you do not actually have a new injury.

While there is not much you can do about your worker’s compensation history, it is important, to be honest and upfront about prior claims. An insurance company will be able to find them anyway, so hiding them only makes things worse.

 

4. The Employee’s Story Is Inconsistent or Suspicious

When employees lie about an injury, there is often some inconsistency in how the accident happened. That inconsistency might be when you report to your employer, or it could be when you talk to a doctor. Insurance companies are on the lookout for any discrepancy that makes you seem less credible if they want to contest your claim.

It can be hard to remember the facts of a work injury. It is a good idea to write down the events that you remember as soon as you can after an accident. Then, you can look back at what you wrote down to refresh your recollection if you forget specific details as you move through your case.

Other Types of Workers’ Compensation Fraud

On the other side of the table, it is important to note that workers’ compensation scams can be committed by employers and healthcare providers as well. You may follow all the rules and still experience problems getting the benefits you deserve and need to recover. When companies and healthcare providers cheat the system, everyone suffers.

Insurance Premium Fraud

Insurance premium fraud is committed when an employer pays workers less than what they are entitled to receive under Pennsylvania law. Misclassifying employees as independent contractors is one of the most common ways that this type of fraud occurs.

Healthcare Provider Fraud

Doctors and other medical care providers can also engage in workers’ comp fraud. There have been reports of massive schemes where doctors state that they provided care when they did not, just to get reimbursed by the insurance carrier that is providing benefits to the worker.

Contact a Pennsylvania Workers’ Compensation Attorney Today

If you are being accused of worker’s compensation fraud, it is especially important to involve an experienced workers’ compensation lawyer to help with your case. You need experienced, compassionate legal representation to protect your interests.

The workers’ comp lawyers at Krasno Krasno & Onwudinjo will fight for what you deserve and prevent insurance companies from taking advantage of you. We can help you present your case in a way that will increase your chances of getting benefits and decrease accusations of workers’ compensation fraud.

Our team understands how frustrating it can be to manage a workers’ comp claim while trying to heal. Adding a false allegation of fraud only increases the stress on you and your family. Let us take these burdens off your shoulders and keep you on track to get better. Call our lawyers today for more information, or use our online form (also available to the left of this post) to schedule a free case review.