January 06, 2010

By many accounts, fraud in workers' compensation cases is relatively rare — estimated at about one percent of cases reported each year in California. However, if your company is part of that unfortunate one percent, it can be a significant cost. Here are some red flags to watch out for:

When Can You Deny a Workers' Compensation Claim?

Join us on January 21 for an in-depth webinar — specifically for California employers — to learn the affirmative defenses to workers' comp claims brought by your workers.

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• Reporting that is not timely. Employees should be regularly reminded that injuries and illnesses should be reported as soon as they occur. This helps to ensure the injury is treated promptly, preventing exacerbation; allows for thorough investigation of the incident to prevent future harm to employees; and helps to remove suspicion surrounding the claim.
• The employee is vague about the date, time, place, and details of the accident. With an injury or illness that has a slow onset over time, an employee may not be clear about when symptoms first appeared and what he or she was doing. However, an employee should be able to provide a reasonable amount of detail if there was a specific occurrence that caused an injury. If he or she can't, you should investigate further and try to locate other employees who may have witnessed the accident.
• The details change. As noted above, an employee should be able to recount the details of a specific occurrence that caused an injury. If the employee changes the details during the course of the investigation, you may have a fraudulent claim (another, often more likely, possibility, is that your employee was doing something he or she knew was wrong and is attempting to hide it. In that case, you will still want to get the facts straight and properly address the behavior that resulted in the accident).
• The employee has a history of filing injury claims. If you have a "frequent flyer" when it comes to injury claims, you may well have an employee who needs additional training and supervision when it comes to safety — or you may have someone who is filing false claims. Any time you have multiple injury reports on employees — whether they turn into workers' comp claims or not--you should evaluate what is going on with that employee to ensure that the employee has the tools, training, supervision, and any other resources necessary to work safely.
• The employee stonewalls claim management. When an employee behaves in a way that prevents good claims management, such as refusing or delaying diagnostic treatment to confirm an injury, or changing doctors or attorneys frequently, fraud may be a factor. However, before suspecting fraud, look at how you're managing the claim — is the employee behaving this way because he or she is angry or frustrated about the way it's being handled? Ensure that your employee has the necessary information to fulfill his or her responsibilities (such as providing DOSH publications that can help your employee through the claim process) and ensure that you are communicating regularly and clearly with your employee regarding the claim.

Workers' Comp: Horseplay, Intoxication, and Other Circumstances That Can Let You Off the Workers' Comp Hook

In all 50 states, including California, employers are required to provide workers' comp benefits as prescribed by state law. Although the laws vary, each state penalizes and fines employers who fail to fulfill their obligations.

But there are times you can legitimately, legally deny these claims — for example, if a worker is intoxicated on the job, or fooling around in a reckless manner that leads to injury. If you don't know about these affirmative defenses, you could be spending a lot more than you should on your workers' comp bills.

Join us on January 21 for an in-depth webinar — specifically for California employers — to learn the affirmative defenses to workers' comp claims brought by your workers. Bring your managers and supervisors along so you can jointly formulate your strategy. You'll learn:

• What the employer liability exceptions are to workers' compensation claims, and which are most commonly used
• When to conduct pre-employment screenings for drugs and alcohol or pre-existing injuries, diseases, or conditions
• The art of the investigation — what to look for, who to interview, and how to document it
• What you need to know about post-accident drug testing
• The nuts and bolts of initial claims handling — what needs to be reported and why
• The scenarios in which employers have used affirmative defenses and how they made their case
• Fighting claims in which injuries were falsely reported, a pre-existing condition exists or the injury occurred off-site

Register Now »

Learn More »