Things You Should Know about Workers’ Compensation Fraud
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Workers’ compensation fraud can be perpetrated by the worker, employer or insurance provider. If a worker is found guilty of such fraud, he can be denied benefits completely.
Let’s first understand what fraud comprises. Faking injuries, filing multiple claims, providing false information about an injury, and not reporting the correct amount of your income can lead you to a workers’ compensation fraud case.
Through years of practice as Chicago’s top Workers Compensation lawyers, we have realized that workers’ compensation fraud perpetrated by a worker is not always deliberate. This happens due to the lack of knowledge.
So, which actions of the employee can lead to workers’ compensation fraud?
1. Exaggerating Symptoms
You need to be completely transparent in the revelation of your injuries and symptoms. You may be at the risk of losing your claims if you exaggerate the state of your symptoms and stay away from work, when you are actually capable of going to work and doing your job. Refrain from doing this under all circumstances. State only what the authorized medical professional says about your condition. Excessive medical treatment and an insistence to not return to work can make employers suspicious about your condition and claim.
2. Taking another Job
You are staying off work only because your medical condition isn’t permitting you to be at work. If you take up another job in this period, you will be committing fraud. There are several ways your employer can find out about such actions of yours. He/She can then call your claims representative and put you under surveillance.
3. Faking an Injury
In some cases, employees fabricate an injury to draw the coverage and get paid time off work. This, when detected by the employer, can lead to severe consequences. Such acts should not be attempted under any circumstances.
4. Repeat Claims
Repeat claims trigger fraud alerts. However, a smarter business organization sees this as a sign to look into its internal operations and functions. If it is detected that the working conditions haven’t improved for the worker post the first injury or illness, the case against the company weakens.
How Is Workers’ Compensation Investigated?
If you think you can get away with worker’s compensation fraud, think again. Any claim that appears even mildly suspicious is looked into thoroughly. Background checks are done and often surveillance is warranted. Here are a few elements of your case that can alert a claims representative or an employer:
- When medical notes do not match with the injury report
- Knowing that the claimant has a criminal history
- Getting to know that the claimant has taken up another job in the disability period
However, workers often fall into compensation fraud unintentionally. Sometimes, something as simple as misinterpreting a question in the claims form and responding accordingly can be ascertained as a lie by the claim investigator. In such cases, you need to have a strong defense to claim your benefits and avoid being penalized.
We will discuss the two strongest defenses for workers’ compensation fraud below.
Lack of Enough Evidence of Fraud
Conflicting diagnosis has always been the root cause of fraud allegations. If your healthcare provider diagnoses you with a mental disorder or emotional distress, while the insurer’s physician claims that you are faking your condition, it’s going to be difficult to prove you have committed fraud.
Lack of Fraudulent Intent
To prove that you have committed fraud, the intent to commit fraud is essential. The language in the workers’ compensation form is often found to be ambiguous. Thus, misreading and responding to a question, or missing out on providing pertinent details is not necessarily a deliberate commission of fraud. To receive your claims and not face conviction, you need to assert and prove the lack of fraudulent intent in your actions.
What Are the Preventive Measures One Can Take to Ensure Such a Situation Does Not Arise?
1. Get a Clear Understanding of Your Employer’s Workers’ Compensation Coverage
Ask your employer for the workers’ compensation brochure. Read it back-to-back. Find your state’s workers’ compensation program and check the information on its website. Now verify and double check the information, and then embark on the claims process.
2. Be Sure to Stay Sober at Work
If you were not sober at the time the injury happened, the chances of receiving compensation benefits are almost completely eliminated. Most employers will make you undergo a drug test, and if you test positive, you worker’s compensation claim will be rejected.
3. Have Clear and Detailed Medical Records
The employee’s medical records are the key to a workers’ compensation case. They should clearly mention the circumstances of your injury and if you had any prior injury in the same place. It’s necessary that you mention every body part that has been injured and that you may require further treatment. The greater clarity you provide in your medical records, the more secure you will be of receiving appropriate compensation. Also, in the event of workers’ compensation fraud, these will help you frame a strong defense.
While this post concentrates on the issues of workers’ compensation fraud by employees, several such frauds are also committed by employers and insurance providers. From changing evidence to deny a worker’s claim to lying about the accident or the job conditions, insurer and employer frauds are not rare. If you suspect your employer or insurer of committing such a fraud with you, seek professional legal assistance, know more about your rights and get your case evaluated before proceeding on a course of action.
We at Kosin Law Office, LTD. have handled thousands of workers’ compensation claims and legal cases.
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