Do you want to protect your business from fake injury claims?
Business owners waste millions of dollars each year on fraudulent claims that could have been prevented. The National Insurance Crime Bureau reports that workers’ compensation fraud costs $30 billion annually in the United States. That’s money out of the pockets of legitimate businesses like yours.
Here’s the good news:
The majority of false claims are the same. You’ll recognise the warning signs a mile off when you know what to look for.
Below are the major red flags when an employee files an occupational injury claim.
Let’s get into it!
Here’s what’s inside:
- Why Spotting Red Flags Matters
- The Biggest Red Flags In An Occupational Injury Claim
- What To Do When You Spot A Red Flag
Why Spotting Red Flags Matters
When you’re running a business, you’re going to get some occupational injury claims. Most are completely valid. But some, not so much.
False claims drive up your insurance costs, waste your time, and damage morale. Early intervention is key. A workers comp attorney in Fresno can evaluate a questionable job injury claim, inform you of your rights as an employer, and help build your case when the facts don’t line up.
Here’s the kicker:
Up to 30% of workers’ comp claims are estimated to be fraudulent in some areas. That’s why you need to be extra diligent about every workers’ compensation claim.
Ignoring red flags can cost you:
- Money — fraudulent payouts and higher premiums
- Time — investigations and legal back-and-forth
- Trust — honest employees feel disrespected when scammers get away with it
The Biggest Red Flags In An Occupational Injury Claim
Alright, now for the important part. Here are the red flags that an occupational injury claim is not genuine.
One red flag is meaningless. Two or three is the point where you start investigating.
The Monday Morning Injury
This is the most common red flag out there.
An employee comes in on Monday and reports they were injured late Friday. Or the injury “occurs” first thing on Monday before anyone has seen them work.
Why should you be suspicious? Sports, yard work or home project injuries taken on the weekend are sometimes blamed on an accident that occurred at work on Monday. It’s an old fraudster’s trick to pass personal medical expenses to your business.
Legit injuries do happen on Mondays. But if late reporting is involved, ask questions.
No Witnesses At All
Most on-the-job accidents that really happen have witnesses. Fellow employees, foremen, video surveillance — someone typically saw what occurred.
An employee saying they were injured and no one witnessed the injury is a red flag, particularly if the alleged injury was in a high-traffic area.
Ask yourself:
- Was the area normally populated?
- Does the employee’s story match the location?
- Are there cameras that could confirm it?
If the answers don’t line up, you have a problem.
Conflicting Accident Details
Real injuries are easy to remember. Fake ones are hard to keep straight.
An evolving story as to time, place, activity and/or mechanism of injury is suspicious. As is a description of the event which is inconsistent with the medical report.
Watch out for:
- Vague or fuzzy details
- Story changes between tellings
- Claims that don’t match the medical findings
- Details that don’t fit their job duties
When the story shifts every time, there’s usually a reason.
Timing Around Job Issues
Here’s a huge one… Check the timing.
Did the injury occur immediately following a write-up? Right before a layoff? At the end of a seasonal job? Immediately after being denied a promotion?
Unhappy employees are significantly more likely to file fraudulent workers’ compensation claims. They do this as retaliation against the company and for additional financial gain before they depart.
Timing alone isn’t proof. But with other red flags, it tells a story.
History Of Past Claims
Some people game the system. They have filed claim after claim at various jobs. Often with the same injuries and/or the same doctors.
Dig deeper if your new hire has an extensive history of occupational injury claims, particularly litigated claims. Ditto employees who often change doctors, addresses, or employers.
This pattern is called “claim shopping” and it’s a classic sign of fraud.
Refusing Medical Treatment
A legitimately hurt worker is interested in healing. They attend appointments and are compliant during testing.
A fake claimant does the opposite.
Red flags here include:
- Refusing a diagnostic procedure
- Skipping physical therapy
- Avoiding independent medical evaluations
- Pushing back on tests that could disprove the injury
If the employee doesn’t want to be examined, ask yourself why.
Social Media Contradictions
This one is gold. Social media has caught tons of fraudsters red-handed.
You wouldn’t believe how many “seriously injured” employees are posting pictures of themselves skiing, playing sports, or doing renovations while on benefits. If you think something is up, a little public social media snooping can tell you a lot.
Just keep it above board and only look at publicly available info.
New Employees Filing Fast
An employee on the job 30 days or less is a classic red flag. Not always fraudulent, but when combined with other red flags that are piling up this one is worth investigating. New hires who come on with pre-existing injuries sometimes try to lay them off on the new employer.
What To Do When You Spot A Red Flag
Have you spotted one or more of these red flags? Calm down. And don’t point fingers just yet.
Here’s what you should do:
- Document everything — Write down every detail, inconsistency, and witness statement.
- Interview witnesses separately — Talk to each person while memories are fresh.
- Review video footage — Check any cameras that might have captured the incident.
- Talk to your insurance carrier’s SIU — Special Investigation Units are designed for this.
- Get legal help — An experienced attorney can guide you through the next steps.
The objective is to protect your business without violating employee rights. That’s a fine line, so seek professional advice sooner rather than later.
Final Thoughts
Identifying a fraudulent occupational injury claim is a matter of being aware of the warning signs. While no one of these red flags is evidence of fraud taken alone, it is time to take notice when they start piling up.
To quickly recap the biggest red flags:
- Monday morning injuries with no witnesses
- Constantly changing accident details
- Suspicious timing around job issues
- A long history of past claims
- Refusal to follow through with medical treatment
- Social media posts that contradict the injury
Document. Act quickly. Get the professionals involved. Your business should have this protection.
