Studies show that only 1%-2% of workers' comp claims are fraudulent—but that doesn't stop insurers, employers, and politicians from publicizing the cases of fraud that do happen in a way that makes it seem like the entire system is just one big gold mine for greedy employees to plunder. The problem for many employees who have legitimate claims is that they can fall under suspicion of fraud just because they fit certain "red flags" that insurers give employers. How do you know if you're at risk of being suspected of workers' comp fraud? What do you do if you think you're being targeted for investigation?

1.) Be conscious of the factors that make your claim seem suspicious.

There are a number of circumstances that can put you on the insurance company's radar, even though you're innocent:

  • You file your report Monday morning. This makes your employer suspicious that you were injured over the weekend and are trying to scam workers' comp into paying for it.
  • There weren't any witnesses to your accident—despite the fact that you were assigned to an area by yourself.
  • You've changed treating physicians several times. You may have a perfectly legitimate reason, such as dissatisfaction with your level of care, but your employer may claim that you are "shopping" for a diagnosis to support your claim.
  • Your employer complains that you are hard to reach. That is a sign that he or she is checking to see if you're really sitting at home, unable to work.
  • You remember new details about the accident that you didn't mention in your initial report (which can easily happen as your shock wears off and you have time to collect your thoughts).
  • You have alimony or child support garnishment coming out of your paycheck. Anybody with obvious financial trouble is likely to fall under suspicion.

One situation that almost always puts an injured employee on the "suspect" list for fraud is getting injured during the first few days on the job—despite the fact that studies show that newly-hired workers are simply at greater risk of injury, probably because they're still untrained and unfamiliar with the hazards of their new job. 

2.) Try to address the issues head-on, if you think that your manager is receptive.

Ideally, you can avoid being the target of suspicion simply by addressing the issues head on. If you know that something about your claim makes you seem like you might be trying to get benefits for nothing, try bringing up the issue to your manager or supervisor in order to allay his or her concerns.

For example, if you were injured while you were still training on a piece of equipment, keep in mind that it doesn't hurt you to simply admit that you weren't fully prepared to handle the job on your own yet. Many people are afraid to admit that they share any possible responsibility for their own injuries because they either don't know or forget that workers' comp is a no-fault system. Neither your negligence (for trying to operate the equipment before you were ready) nor your employer's negligence (for not making sure you were fully trained) makes any difference—you're still entitled to benefits no matter who is at fault.

3.) If you still feel like you are under suspicion, be cautious and contact an attorney.

Keep in mind that insurers do aggressively pursue suspected fraud—which means that they may try to catch you doing something that you aren't supposed to be able to do. Always keep in mind how something looks on film. For example, if you're caught on film lifting a bag of groceries when you're supposed to be unable to work from a back injury, you'll look guilty of fraud—the camera won't capture the 3 hours or so that you spent in agony sitting with an ice pack on your back as you tried to recover from that simple task.

If you think you are being followed, you probably are. If you hear rumors that your boss thinks you are lying about your injuries, don't dismiss them. Assume that you're under suspicion and consider contacting an attorney as soon as possible. If the surveillance you're under becomes harassing, or you start having trouble getting your scheduled payments, an attorney can help protect your rights and advise you about what you can and cannot do. He or she can also defend your right to benefits if your employer attempts to terminate them for alleged fraud.

For more information, contact Gilbert, Blaszcyk & Milburn LLP or a similar firm.