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How does an investigator uncover fraudulent workers’ comp claims?

When an employee reports an on-the-job injury in California, you may assume that your workers’ compensation insurance will cover the costs of the medical bills and a portion of the lost wages. However, according to Property Casualty 360, false claims raise the cost of policies, so any red flags may warrant an investigation.

An examiner may recommend further investigation of a claim if there is record that the employee has pre-existing health problems, family or money issues, or is in a rush to settle the claim. Other indications that there may be fraud include injuries that occur in a situation that your employee should not have been in or injuries that are much higher than the accident conditions would signify. A lack of witnesses or refusal to provide evidence of the loss may also generate suspicion of the need for further examination.

While you may think that you will need someone to follow your employee around and document behaviors, the investigator you hire may be able to conduct all necessary transactions by telephone, or through a visit to the workplace. In some cases, telephone interviews may be sufficient to gather eye-witness accounts and identify the employee’s failure to provide proper records or documentation. If an investigator needs to speak to people in person, examine personnel records or inspect the area where the accident allegedly happened, he or she may need to come to the job site.

If you have received reports that the employee is participating in activities that could have caused the injury or is working at another job, an in-depth investigation may be necessary, after all. This general information is provided to help you assess whether to pursue an investigation of an employee. However, it should not be interpreted as legal advice.

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