Using available resources to uncover workers’ compensation abuse

June 30, 2014

This fraud case is a reminder for employers to utilize available tools and resources to help uncover workers’ compensation claim abuses. In this particular situation, an employer reviewed their internal security video footage which revealed an alleged workers’ compensation injury never occurred.

A health food store hired an employee to stock shelves and move merchandise. Nine months after being hired the employee filed a workers’ compensation claim for an alleged back injury. The claimant reported that the injury occurred when he lifted a bag of oats over his head and twisted, pulling a muscle in his back.

After the employer received notice of the workers’ compensation claim, he reviewed the footage from the on-site security cameras and discovered the claimant did not perform the action described in his claim. The employer immediately contacted the CompSource Mutual claims adjuster to share this information.

The adjuster referred the claim to the CompSource Mutual Special Investigations Unit (SIU) and after investigating the claimant’s background, learned he had filed previous workers’ compensation claims for back injuries. When he completed his employment application, the claimant stated he had no problems with his back and was capable of performing lifting as part of his job responsibilities. 

The investigator and adjuster scheduled the claimant for a deposition, but it was postponed when the claimant’s attorney learned the store’s security footage was available.

The claim quickly went into “denied” status and the case was presented to the Office of the Attorney General. The claimant pled guilty to workers’ compensation fraud and received a three-year deferred sentence and was ordered to pay restitution.

If you question the validity of a claim, contact your claims adjuster or notify our Special Investigations Unit by calling (800) 899-1847 or visiting our website at www.compsourceok.com.