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  • Writer's pictureRobert Schuerger

Cracking the Code: What Do Workers' Comp Investigators Look For?

In a world where workplace safety is increasingly prioritized, workers' compensation claims have seen a significant decline. However, the darker side of this trend is the rise of workers' compensation fraud, which has led to more stringent investigations.


The methods used by insurance companies to detect fraud can sometimes ensnare innocent injured workers as well, making it crucial for claimants to understand the complexities of these workers' comp investigations.


With the growing number of workers' compensation investigations, it becomes essential to examine the motives, techniques, and implications for both genuine and fraudulent claimants. Contact Schuerger Shunnarah Trial Attorneys to find out who is exempt from workers compensation.


What Is Workers' Compensation Fraud?

What Is Workers' Compensation Fraud?


Workers' compensation fraud occurs when an individual deceitfully receives financial gains. It can be committed by various parties, including employees, employers, insurance companies, and even medical providers.


Gaining a clear understanding of the actions that constitute fraud is vital to avoid unintentional missteps that could lead to the denial of a legitimate workers' compensation claim or being ensnared by investigations designed to catch fraudulent activities.


The following actions can be considered workers' compensation fraud when committed by employees:

  1. Falsifying an injury or illness,

  2. Misrepresenting a non-work-related injury as work-related,

  3. Working while receiving total disability benefits,

  4. Exaggerating injuries or illnesses,

  5. Misreporting income, and

  6. Seeking reimbursement for unobtained medications or treatments.

By recognizing the actions that constitute workers' compensation fraud, employees can avoid inadvertently jeopardizing their legitimate claims.


Staying informed and vigilant is crucial to navigating the complex world of workers' compensation investigations and ensuring that valid claims are not undermined by fraudulent activities.


Understanding Workers' Compensation Fraud Investigations


Workers' comp fraud is a significant concern for insurance companies, leading them to conduct thorough investigations into suspicious claims.


These investigations typically involve teams of private or in-house investigators specializing in workers' comp cases. Their primary goal is to uncover evidence of fraudulent activities, such as fake injuries, exaggerated claims, or non-work-related incidents.


Common Methods Used in Workers' Comp Investigations


Inspectors for worker's comp use various techniques to gather evidence and determine the legitimacy of a claim. Some of the most common methods include:

  1. Video surveillance: Investigators can analyze security footage from medical facilities, workplaces, and other public locations to identify inconsistencies in a claimant's reported injuries or actions that contradict their workers' comp claim.

  2. Online surveillance: They can monitor social media and other online platforms to gather information about claimants, such as status updates, tagged photos, and posts that may contradict their claims for compensation.

  3. Interviews: These agents can also interview claimants, their friends, family members, coworkers, and other witnesses to collect statements and look for differences in the provided information.

Red Flags in Workers' Comp Claims


Certain indicators can prompt an insurance company to launch a workers' comp investigation. These red flags include:

  • Claimants who are unavailable for calls, exams, or appointments,

  • Claims filed at the end of seasonal or temporary work,

  • Inconsistencies between reported limitations and observed activities,

  • History of filing multiple claims,

  • Lack of eyewitnesses or conflicting accounts of the incident,

  • Continued work despite claiming "total disability" benefits, and

  • Sharing prescribed narcotics or attempting to get multiple prescriptions.

The Impact of This Investigation


A thorough investigation can lead to denying fraudulent claims, protecting insurance companies, and ensuring that legitimate claimants receive the benefits they deserve.


However, the investigation process can also be invasive, causing stress and anxiety for those under scrutiny.


It is essential for claimants to understand the potential consequences of a workers' comp investigation and take necessary precautions to protect their rights.


This may include consulting with a workers comp attorney in Houston, maintaining privacy on social media, and adhering to medical advice and treatment plans.


Common Questions Asked by Workers' Compensation Investigators


Investigators often ask a series of questions to determine the legitimacy of a claim.

Moreover, these questions can include inquiries about the accident details, location, witnesses, the claimant's job responsibilities, the nature of the injury, adherence to company safety protocols, and previous workers' compensation claims, among others.


By preparing for these questions and formulating consistent answers, claimants can minimize the chances of being caught off guard during the investigation process.


The Duration of a Workers' Comp Investigation


These investigations typically last between 14 to 30 days, as most states require employers and insurance companies to make a decision on a claim within a reasonable timeframe.


Furthermore, the speed of the investigation often depends on the investigator's ability to gather necessary information promptly. In some cases, the insurance company may request an extension if additional time is needed to gather evidence.


The Importance of Caution During This Investigation


When a workers' compensation claim is being investigated, it is crucial for claimants to be cautious and mindful of their actions.


Claimants should always assume that a workers' compensation investigator is observing them and refrain from posting contradictory information on social media or engaging in activities that could jeopardize their claim.


The Role of a Workers' Compensation Attorney


In some instances, insurance companies may use workers' compensation investigations to intimidate claimants, leading them to drop their claims or settle for lesser amounts.


If a claimant is accused of workers' compensation deceit or other insurance fraud, having an experienced attorney can be invaluable in defending their rights and refuting false allegations.


Factors That May Trigger the Investigation


The insurance company may initiate a workers' compensation investigation if they suspect the claimant of faking their injury, exaggerating the severity of their injury, working elsewhere during their claim, or engaging in workers' compensation fraud.


By conducting these investigations, insurance companies can protect the integrity of the workers' compensation system and ensure that benefits are only paid to deserving claimants.


Recognizing the Signs of a Workers' Compensation Investigation

Recognizing the Signs of a Workers' Compensation Investigation


In many cases, claimants may not know that they are under investigation, as private investigators are trained to be discreet and subtle.


However, there are some signs that could indicate surveillance, such as noticing the same vehicle repeatedly in public places or receiving inquiries about the claimant's injury from friends or family.


The Bottom Line


Investigations are an essential element in maintaining the integrity of the workers' compensation insurance system. They help protect both claimants and insurance companies from the detrimental effects of workers comp fraud. Schuerger Shunnarah Trial Attorneys can also help answer questions like, "Why do employers fight workers comp claims?"


A thorough workers comp investigation conducted by skilled investigators can ensure that legitimate claims are validated and fraudulent activities are identified. In this complex landscape of workers' compensation law, it is crucial for claimants to be well-informed and prepared.


If faced with challenges in dealing with workers' comp claims, investigations, or dealing with health care providers, do not hesitate to contact Schuerger Shunnarah Trial Attorneys for professional assistance and guidance.

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