Fraud case of the quarter: Inconsistencies lead to an investigation

June 8, 2012

Policyholders are instrumental in identifying workers’ compensation fraud committed by claimants. A recent case of fraud was discovered when an employer noticed that the details of the alleged injury were inconsistent, a common red flag indicating workers’ compensation fraud.

The claimant gave an elaborate account of the accident, which the policyholder felt was questionable. After the policyholder notified CompSource Mutual, a claims adjuster arranged for an investigator to interview company employees and verify facts about the job site. The investigation and photographs of the scene made it apparent that the claimant’s story was embellished, if not completely fabricated.

The chart below compares the details the claimant reported and the facts discovered through the investigation.

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After review of the discrepancies in the reported events and the facts obtained, it was determined that the claimant made criminal misstatements concerning the incident. The case was referred to the Oklahoma Attorney General’s office for further action. In the end, the claimant was convicted of workers’ compensation fraud.

In this case, it was the inconsistencies between the details the claimant offered and the facts revealed through the investigation that led to the discovery of workers’ compensation fraud. Employers should be aware of the types of fraud that are committed and signs that it might be occurring. Keeping these red flags in mind can protect your company from fraud.

If you are questioning the validity of a claim, contact your claims adjuster or notify our special investigations unit by calling (800) 899-1847 or clicking here.