4 Red Flags of Workers’ Compensation Fraud & How to Avoid Them

Workers’ compensation is designed to help injured workers recover from a work accident. 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.

However, employers are wary that some employees may “fake” injuries so that they can get benefits without having to work. This is referred to as workers’ compensation fraud.

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

What is Workers’ Compensation Fraud?

Workers’ compensation fraud mainly refers to any time a worker makes a false statement or hides information from an employer or insurance company regarding a work injury so they can receive benefits. Some people may try to do this because the work comp benefits are very appealing.

These include:

  • Payment of medical benefits
  • Lost wage payments
  • Permanency benefits for loss of function in the future
  • Vocational rehabilitation

Unfortunately, those who attempt to trick employers and insurance companies into paying them benefits abuse the system in a way that ends up hurting everyone.

Other Types of Workers’ Compensation Fraud

It is also important to note that there are cases of employers and others committing workers’ compensation fraud as well.

Premium Fraud

An employer could engage in fraud to pay workers less than what they are entitled to receive under Pennsylvania law, for example. Misclassifying employees as independent contractors is one of the most common ways that this type of fraud occurs.

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 company that is providing benefits to the worker.

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
  • 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 (malingering)

Insurance companies will be on the lookout for these common types of work comp fraud.

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 he or she has been released to do so because they have gotten used to the workers’ compensation payments and simply have no motivation to go back to work. Often, malingering includes a fear that going back to work 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 as well. It is very important to participate in all necessary treatment unless you speak with your attorney about your legitimate reason for not attending.

2. The employee did not report the injury right away.

You must report a work injury to your employer as soon as possible. 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 he injured his 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’ compensation 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 workers’ 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.

Contact a Pennsylvania Workers’ Compensation Attorney

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.

The workers’ comp lawyers at Krasno Krasno & Onwudinjo can help you present your case in a way that will increase your chances of getting benefits and decrease accusations of workers’ compensation fraud.

Call our lawyers today for more information, or use the form to the left to schedule a free case review.