Plenty of employees are actually injured on the job every day in Iowa, but research also shows that some employees claiming workers compensation benefits are not being honest. Iowa law defines workers compensation fraud as making any claim to an insurer, whether written or oral, containing any false information for the purpose of receiving benefits.
How can you determine whether a worker has legitimately injured himself or is trying to defraud the insurance system and his employer? Here are a few tips for identifying workers comp fraud:
- Look at the timing. Be wary of injuries right before or after a vacation, layoff or on a Monday morning. Adjusters should always check medical records for the injury date.
- New hires. One common thread seems to be newer hires claiming an injury that puts them out for over a year. On the other hand, statistics show people newer to a job are genuinely more likely to suffer from a job-related injury due to lack of experience.
- Disgruntled employees. This group has long been a pool for likely fraud candidates.
- Common doctors and lawyers. Insurance companies are starting to notice that certain doctors and lawyers repeatedly work on these cases, which should arouse suspicion.
- The type of injury. This factor has become the biggest warning sign of fraud. Concussions have become common, especially in professional sports. Soft tissue injuries are notoriously hard to prove or disprove.
- The story doesn't add up. You may have a hard time getting a clear description of what happened to cause the injury, and there are no witnesses. The employee may also refuse to have a medical diagnostic procedure, such as an x-ray. You may even hear other employees gossiping about the injury.
Often, cases involving concussion or soft tissue injuries come down to credibility. That may mean credibility of the employee, employer or the doctors involved. Proving a person does not have a headache or sore muscles is difficult, at best. You will have to rely on good documentation.
If you suspect an employee has filed a false workers comp claim, make sure you follow all procedures carefully and collect as much documentation as you can before turning it over to your claims adjuster. Some cases warrant a private investigator to look into the claims. Proving fraud is not always easy, but it is possible.